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Objective To investigate survival in children referred from primary care in Malawi, with a focus on hypoglycaemia and hypoxaemia progression. Methods The study involved a prospective cohort of children aged 12 years or under referred from primary health-care facilities in Mchinji district, Malawi in 2019 and 2020. Peripheral blood oxygen saturation (Sp[O.sub.2]) and blood glucose were measured at recruitment and on arrival at a subsequent health-care facility (i.e. four hospitals and 14 primary health-care facilities). Children were followed up 2 weeks after discharge or their last clinical visit. The primary study outcome was the case fatality ratio at 2 weeks. Associations between Sp[O.sub.2] and blood glucose levels and death were evaluated using Cox proportional hazards models and the treatment effect of hospitalization was assessed using propensity score matching. Findings Of 826 children recruited, 784 (94.9%) completed follow-up. At presentation, hypoxaemia was moderate (Sp[O.sub.2]: 9093%) in 13.1% (108/826) and severe (Sp[O.sub.2]: < 90%) in 8.6% (71/826) and hypoglycaemia was moderate (blood glucose: 2.5-4.0 mmol/L) in 9.0% (74/826) and severe (blood glucose: < 2.5 mmol/L) in 2.3% (19/826). The case fatality ratio was 3.7% (29/784) overall but 26.3% (5/19) in severely hypoglycaemic children and 12.7% (9/71) in severely hypoxaemic children. Neither moderate hypoglycaemia nor moderate hypoxaemia was associated with mortality. Conclusion Presumptive pre-referral glucose treatment and better management of hypoglycaemia could reduce the high case fatality ratio observed in children with severe hypoglycaemia. The morbidity and mortality burden of severe hypoxaemia was high; ways of improving hypoxaemia identification and management are needed. Objectif Analyser le taux de survie des enfants transferes depuis les soins primaires au Malawi, en se focalisant sur l'evolution de l'hypoglycemie et de l'hypoxemie. Methodes Cette etude a ete menee sur une cohorte prospective d'enfants ages de maximum 12 ans et ayant fait l'objet d'un transfert depuis des etablissements de soins primaires situes dans le district de Mchinji, au Malawi, en 2019 et 2020. La saturation en oxygene du sang peripherique (Sp[O.sub.2]) et la glycemie ont ete mesurees lors de la selection ainsi qu'a l'arrivee dans le centre de soins suivant (c'est-a-dire l'un des quatre hopitaux ou des 14 etablissements de soins de sante primaires). Les enfants etaient suivis deux semaines apres leur sortie ou leur derniere visite clinique. Le resultat de l'etude primaire correspond au taux de letalite a deux semaines. Nous avons utilise des modeles a risques proportionnels de Cox pour identifier les liens entre la Sp[O.sub.2], le taux de glycemie et le deces, et un appariement des coefficients de propension pour evaluer l'effet therapeutique de l'hospitalisation. Resultats Sur 826 enfants selectionnes, 784 (94,9%) sont arrives au terme du suivi. Au moment de leur presentation, l'hypoxemie etait moderee (Sp[O.sub.2]: 90-93%) chez 13,1% (108/826) et severe (Sp[O.sub.2]: < 90%) chez 8,6% d'entre eux (71/826). De son cote, l'hypoglycemie etait moderee (glycemie: 2,5-4,0 mmol/L) chez 9,0% (74/826) et severe (glycemie: < 2,5 mmol/L) chez 2,3% d'entre eux (19/826). Le taux de letalite s'elevait a 3,7% (29/784) au total, mais a 26,3% (5/19) chez les enfants souffrant d'hypoglycemie severe et a 12,7% (9/71) chez ceux souffrant d'hypoxemie severe. Ni l'hypoglycemie moderee, ni l'hypoxemie moderee n'etaient associees au deces. Conclusion Un traitement presomptif avant le transfert et une meilleure gestion de l'hypoglycemie pourraient reduire le haut taux de letalite observe chez les enfants souffrant d'hypoglycemie severe. La charge de morbidite et de mortalite imputable a l'hypoxemie severe etait considerable; il est donc imperatif d'ameliorer le diagnostic et la gestion de l'hypoxemie. Objetivo Estudiar la supervivencia de los ninos remitidos desde la atencion primaria en Malawi, con un enfoque en la evolucion de la hipoglucemia y la hipoxemia. Metodos El estudio incluyo una cohorte prospectiva de ninos de 12 anos o menos remitidos desde centros de atencion primaria de salud ubicados en el distrito de Mchinji, Malawi, en 2019 y 2020. La saturacion de oxigeno en sangre periferica (Sp[O.sub.2]) y la glucemia se midieron en el momento de seleccion y a la llegada a un centro sanitario posterior (es decir, cuatro hospitales y 14 centros de atencion primaria). Se realizo un seguimiento de los ninos dos semanas despues del alta o de su ultima visita medica. El resultado principal del estudio fue la tasa de mortalidad a las dos semanas. Las asociaciones entre los niveles de Sp[O.sub.2] y de glucemia y la muerte se evaluaron mediante modelos de riesgo proporcional de Cox, y el efecto del tratamiento de la hospitalizacion se evaluo mediante el emparejamiento del indice de propension. Resultados De los 826 ninos seleccionados, 784 (94,9 %) completaron el seguimiento. Cuando se presentaron, la hipoxemia era moderada (Sp[O.sub.2]: 90-93 %) en el 13,1 % (108/826) y grave (Sp[O.sub.2]: Conclusion El tratamiento presunto de la glucosa antes de la remision y el mejor tratamiento de la hipoglucemia podrian reducir la elevada tasa de letalidad que se observa en los ninos con hipoglucemia grave. La carga de morbilidad y mortalidad de la hipoxemia grave fue elevada; en consecuencia, es preciso mejorar la identificacion y el tratamiento de la hipoxemia. [phrase omitted], Introduction Global initiatives to reduce child mortality have generally focused on improving early access to basic treatment for common illnesses using tools such as the World Health Organization's (WHO) Integrated [...]

Objective To present findings from implementation and scale-up of human immunodeficiency virus (HIV) self-testing programmes for female sex workers in Malawi and Zimbabwe, 2013-2018. Methods In Zimbabwe, we carried out formative research to assess the acceptability and accuracy of HIV self- testing. During implementation we evaluated sex workers' preferences for, and feasibility of, distribution of test kits before the programme was scaled-up. In Malawi, we conducted a rapid ethnographic assessment to explore the context and needs of female sex workers and resources available, leading to a workshop to define the distribution approach for test kits. Once distribution was implemented, we conducted a process evaluation and established a system for monitoring social harm. Findings In Zimbabwe, female sex workers were able to accurately self-test. The preference study helped to refine systems for national scale-up through existing services for female sex workers. The qualitative data helped to identify additional distribution strategies and mediate potential social harm to women. In Malawi, peer distribution of test kits was the preferred strategy. We identified some incidents of social harm among peer distributors and female sex workers, as well as supply-side barriers to implementation which hindered uptake of testing. Conclusion Involving female sex workers in planning and ongoing implementation of HIV self-testing is essential, along with strategies to mitigate potential harm. Optimal strategies for distribution and post-test support are context-specific and need to consider existing support for female sex workers and levels of trust and cohesion within their communities. Objectif Presenter les resultats de la mise en reuvre et de I'elargissement de programmes d'autodepistage du virus de l'immunodeficience humaine (VIH) pour les travailleuses du sexe au Malawi et au Zimbabwe entre 2013 et 2018. Methodes Au Zimbabwe, nous avons realise une recherche preparatoire pour evaluer l'acceptabilite et la precision de l'autotest du VIH. Au cours de la mise en reuvre, nous avons evalue la faisabilite et les preferences des travailleuses du sexe a l'egard de la distribution des trousses de depistage avant d'elargir le programme. Au Malawi, nous avons realise une evaluation ethnographique rapide pour etudier le contexte, les besoins des travailleuses du sexe et les ressources disponibles, ce qui a donne lieu a un atelier dont l'objectif etait de definir la methode de distribution des trousses de depistage. Une fois la distribution mise en place, nous avons evalue le processus et etabli un systeme de suivi des dommages sociaux. Resultats Au Zimbabwe, les travailleuses du sexe etaient en mesure de proceder a un autodepistage precis. Letude des preferences a permis de perfectionner les systemes en vue d'un developpement national par l'intermediaire des services existants pour les travailleuses du sexe. Les donnees qualitatives ont aide a definir d'autres strategies de distribution et les dommages sociaux indirects que peuvent subir les femmes. Au Malawi, la distribution de trousses de depistage par des pairs a ete la strategie privilegiee. Nous avons identifie quelques cas de dommages sociaux entre des travailleuses du sexe assurant la distribution et d'autres travailleuses du sexe, ainsi que des obstacles du cote de l'offre qui ont limite l'utilisation du test. Conclusion La participation des travailleuses du sexe a la planification et a la mise en reuvre continue de l'autodepistage du VIH est essentielle, de meme que les strategies visant a reduire les dommages potentiels. Pour etre optimales, les strategies en matiere de distribution et de soutien post-test doivent tenir compte du contexte, du soutien existant apporte aux travailleuses du sexe et du degre de confiance et de cohesion au sein de leurs communautes. Objetivo Presentar los resultados de la implementacion y ampliacion de los programas de autodiagnostico del virus de la inmunodeficiencia humana (VIH) para trabajadoras sexuales en Malawi y Zimbabwe, 2013-2018. Metodos En Zimbabwe, se llevo a cabo una investigacion formativa para evaluar la aceptabilidad y exactitud del autodiagnostico del VIH. Durante la implementacion, se evaluaron las preferencias de las trabajadoras sexuales y la viabilidad de la distribucion de los kits de pruebas antes de ampliar el programa. En Malawi, se realizo una evaluacion etnografica rapida para explorar el contexto y las necesidades de las trabajadoras sexuales y los recursos disponibles, que condujo a un taller para definir el enfoque de distribucion de los kits de pruebas. Una vez implementada la distribucion, se llevo a cabo una evaluacion del proceso y se establecio un sistema para el seguimiento de los danos sociales. Resultados En Zimbabwe, las trabajadoras sexuales pudieron autoevaluarse con precision. El estudio de preferencias contribuyo a perfeccionar los sistemas de ampliacion nacional mediante los servicios existentes para las trabajadoras sexuales. Los datos cualitativos ayudaron a identificar estrategias de distribucion adicionales y a mediar en posibles danos sociales para las mujeres. En Malawi, la estrategia preferida fue la distribucion de kits de pruebas entre pares. Se identificaron algunos incidentes de dano social entre distribuidores pares y trabajadoras sexuales, asi como barreras de suministro para la implementacion que dificultaban la realizacion de las pruebas. Conclusion Es esencial involucrar a las trabajadoras sexuales en la planificacion y la implementacion continua del autodiagnostico del VIH, junto con estrategias para reducir los danos potenciales. Las estrategias optimas para la distribucion y el apoyo posterior a las pruebas son especificas para cada contexto y deben tener en cuenta el apoyo existente a las trabajadoras sexuales y los niveles de confianza y cohesion dentro de sus comunidades., Introduction Female sex workers are a marginalized group who are disproportionately affected by human immunodeficiency virus (HIV) infection. (1) Despite reduction in HIV infections in the general population, the prevalence [...]

Background: In Malawi, female sex workers (FSW) have high HIV incidence and regular testing is suggested. HIV self-testing (HIVST) is a safe and acceptable alternative to standard testing services. This study assessed; whether social harms were more likely to be reported after HIVST distribution to FSW by peer distributors than after facility-based HIV testing and whether FSW regretted HIVST use or experienced associated relationship problems. Methods: Peer HIVST distributors, who were FSW, were recruited in Blantyre district, Malawi between February and July 2017. Among HIVST recipients a prospective cohort was recruited. Interviews were conducted at baseline and at end-line, 3 months later. Participants completed daily sexual activity diaries. End-line data were analysed using logistic regression to assess whether regret or relationship problems were associated with HIVST use. Sexual activity data were analysed using Generalised Estimating Equations to assess whether HIVST use was temporally associated with an increase in social harms. Results: Of 265 FSW recruited and offered HIVST, 131 completed both interviews. Of these, 31/131(23.7%) reported initial regret after HIVST use, this reduced to 23/131(17.6%) at the 3-month follow-up. Relationship problems were reported by 12/131(9.2%). Regret about HIVST use was less commonly reported in those aged 26–35 years compared to those aged 16–25 years (OR immediate regret—0.40 95% CI 0.16–1.01) (OR current regret—0.22 95% CI 0.07 – 0.71) and was not associated with the HIVST result. There was limited evidence that reports of verbal abuse perpetrated by clients in the week following HIVST use were greater than when there was no testing in the preceding week. There was no evidence for increases in any other social harms. There was some evidence of coercion to test, most commonly initiated by the peer distributor. Conclusions: Little evidence was found that the peer distribution model was associated with increased levels of social harms, however programmes aimed at reaching FSW need to carefully consider possible unintended consequences of their service delivery approaches, including the potential for peer distributors to coerce individuals to test or disclose their test results and alternative distribution models may need to be considered. [ABSTRACT FROM AUTHOR]

Introduction: HIV self-testing (HIVST) provides couples and individuals with a discreet, convenient and empowering testing option. As with all HIV testing, potential harms must be anticipated and mitigated to optimize individual and public health benefits. Here, we describe social harms (SHs) reported during HIVST implementation in Malawi, and propose a framework for grading and responding to harms, according to their severity. Methods: We report findings from six HIVST implementation studies in Malawi (2011 to 2017) that included substudies investigating SH reports. Qualitative methods included focus group discussions, in-depth interviews and critical incident interviews. Earlier studies used intensive quantitative methods (post-test questionnaires for intimate partner violence, household surveys, investigation of all deaths in HIVST communities). Later studies used post-marketing reporting with/without community engagement. Pharmacovigilance methodology (whereby potentially life-threatening/changing events are defined as 'serious') was used to grade SH severity, assuming more complete passive reporting for serious events. Results: During distribution of 175,683 HIVST kits, predominantly under passive SH reporting, 25 serious SHs were reported from 19 (0.011%) self-testers, including 15 partners in eight couples with newly identified HIV discordancy, and one perinatally infected adolescent. There were no deaths or suicides. Marriage break-up was the most commonly reported serious SH (sixteen individuals; eight couples), particularly among serodiscordant couples. Among new concordant HIV-positive couples, blame and frustration was common but rarely (one episode) led to serious SHs. Among concordant HIV-negative couples, increased trust and stronger relationships were reported. Coercion to test or disclose was generally considered 'well-intentioned' within established couples. Women felt empowered and were assertive when offering HIVST test kits to their partners. Some women who persuaded their partner to test, however, did report SHs, including verbal or physical abuse and economic hardship. Conclusions: After more than six years of large-scale HIVST implementation and in-depth investigation of SHs in Malawi, we identified approximately one serious reported SH per 10,000 HIVST kits distributed, predominantly break-up of married serodiscordant couples. Both 'active' and 'passive' reporting systems identified serious SH events, although with more complete capture by 'active' systems. As HIVST is scaled-up, efforts to support and further optimize community-led SH monitoring should be prioritized alongside HIVST distribution. Keywords: HIV/AIDS; HIV self-test; HIV testing; social harms; Malawi, 1 | INTRODUCTION Despite concerted efforts to scale-up HIV testing services, in 2017, approximately 25% of people with HIV remain undiagnosed [1]. Globally, men, young people and key populations are [...]

Background: The WHO recommended the use of the RTS,S/AS01 malaria vaccine (RTS,S) based on a pilot evaluation in routine use in Ghana, Kenya, and Malawi. A longitudinal qualitative study was conducted to examine facilitators and barriers to uptake of a 4-dose RTS,S schedule. Methods: A cohort of 198 caregivers of RTS,S-eligible children from communities where RTS,S was provided through the pilot were interviewed three times over a ≈22-month, 4-dose schedule. The interviews examined caregiver perceptions and behaviors. Children's vaccination history was obtained to determine dose uptake. Results: 162 caregivers remained at round 3 (R3); vaccination history was available for 152/162 children. Despite early rumors/fears, the uptake of initial doses was high, driven by vaccine trust. Fears dissipated by R2, replaced with an enthusiasm for RTS,S as caregivers perceived its safety and less frequent and severe malaria. By R3, 98/152 children had received four doses; 34 three doses; 9 one or two doses; and 11 zero doses. The health system and information barriers were important across all under-dose cases. Fears about AEFIs/safety were important in zero-, one-, and two-dose cases. Competing life/livelihood demands and complacency were found in three-dose cases. Regardless of the doses received, caregivers had positive attitudes towards RTS,S by R3. Conclusions: Findings from our study will help countries newly introducing the vaccine to anticipate and preempt reasons for delayed acceptance and missed RTS,S doses. [ABSTRACT FROM AUTHOR]

Introduction: HIV testing has rapidly expanded into diverse, decentralized settings. While increasing accessibility to HIV testing is beneficial, it may lead to unintended consequences such as being pressured to test. We examined the frequency correlates and contexts of pressured HIV testing among Chinese men who have sex with men (MSM) using mixed methods. Methods: We conducted an online survey of MSM (N = 1044) in May 2017. Pressured HIV testing was defined as being forced to test for HIV. We conducted logistic regression analysis to determine the associations between pressured HIV testing and socio-demographic and sexual behavioural factors. Follow-up interviews (n = 17) were conducted with men who reported pressured testing and we analysed qualitative data using a thematic analysis approach. Results: Ninety-six men (9.2%) reported experiencing pressure to test for HIV. Regular male sex partners were the most common source of pressure (61%, 59/96), and the most common form of pressure was a threat to end a relationship with the one who was being pressured (39%, 37/96). We found a higher risk of pressured testing in men who had only used HIV self-testing compared to men who had never self-tested (AOR 2.39 (95%Cl: 1.38 to 4.14)). However, this relationship was only significant among men with low education (AOR 5.88 (95% Cl: 1.92 to 17.99)) and not among men with high education (AOR 1.62 (95% Cl: 0.85 to 3.10)). After pressured testing, about half of men subsequently tested for HIV (55%, 53/96) without pressure--none reported being diagnosed with HIV. Consistent with this finding, qualitative data suggest that perceptions of pressure existed on a continuum and depended on the relationship status of the one who pressured them. Although being pressured to test was accompanied by negative feelings, men who were pressured into testing often changed their attitude towards HIV testing, testing behaviours, sexual behaviours and relationship with the one who pressured them to test. Conclusion: Pressured HIV testing was reported among Chinese MSM, especially from men with low education levels and men who received HIV self-testing. However, in some circumstances, pressure to test helped MSM in several ways, challenging our understanding of the role of agency in the setting of HIV testing. Keywords: HIV; coercion; testing; men who have sex with men; China; mixed methods, 1 | INTRODUCTION Men who have sex with men (MSM) in China are estimated to account for a third of new HIV infections each year [1]. Increasing the coverage and [...]

Background Undiagnosed HIV infection remains substantial in key population subgroups including adolescents, older adults, and men, driving ongoing transmission in sub-Saharan Africa. We evaluated the impact, safety, and costs of community-led delivery of HIV self-testing (HIVST), aiming to increase HIV testing in underserved subgroups and stimulate demand for antiretroviral therapy (ART). Methods and findings This cluster-randomised trial, conducted between October 2018 and July 2019, used restricted randomisation (1:1) to allocate 30 group village head clusters in Mangochi district, Malawi to the community-led HIVST intervention in addition to the standard of care (SOC) or the SOC alone. The intervention involved mobilising community health groups to lead the design and implementation of 7-day HIVST campaigns, with cluster residents ([greater than or equal to]15 years) eligible for HIVST. The primary outcome compared lifetime HIV testing among adolescents (15 to 19 years) between arms. Secondary outcomes compared: recent HIV testing (in the last 3 months) among older adults ([greater than or equal to]40 years) and men; cumulative 6-month incidence of ART initiation per 100,000 population; knowledge of the preventive benefits of HIV treatment; and HIV testing stigma. Outcomes were measured through a post-intervention survey and at neighboring health facilities. Analysis used intention-to-treat for cluster-level outcomes. Community health groups delivered 24,316 oral fluid-based HIVST kits. The survey included 90.2% (3,960/4,388) of listed participants in the 15 community-led HIVST clusters and 89.2% (3,920/4,394) of listed participants in the 15 SOC clusters. Overall, the proportion of men was 39.0% (3,072/7,880). Most participants obtained primary-level education or below, were married, and reported a sexual partner. Lifetime HIV testing among adolescents was higher in the community-led HIVST arm (84.6%, 770/910) than the SOC arm (67.1%, 582/867; adjusted risk difference [RD] 15.2%, 95% CI 7.5% to 22.9%; p < 0.001), especially among 15 to 17 year olds and boys. Recent testing among older adults was also higher in the community-led HIVST arm (74.5%, 869/1,166) than the SOC arm (31.5%, 350/1,111; adjusted RD 42.1%, 95% CI 34.9% to 49.4%; p < 0.001). Similarly, the proportions of recently tested men were 74.6% (1,177/1,577) and 33.9% (507/1,495) in the community-led HIVST and SOC arms, respectively (adjusted RD 40.2%, 95% CI 32.9% to 47.4%; p < 0.001). Knowledge of HIV treatment benefits and HIV testing stigma showed no differences between arms. Cumulative incidence of ART initiation was respectively 305.3 and 226.1 per 100,000 population in the community-led HIVST and SOC arms (RD 72.3, 95% CI -36.2 to 180.8; p = 0.18). In post hoc analysis, ART initiations in the 3-month post-intervention period were higher in the community-led HIVST arm than the SOC arm (RD 97.7, 95% CI 33.4 to 162.1; p = 0.004). HIVST uptake was 74.7% (2,956/3,960), with few adverse events (0.6%, 18/2,955) and at US$5.70 per HIVST kit distributed. The main limitations include the use of self-reported HIV testing outcomes and lack of baseline measurement for the primary outcome. Conclusions In this study, we found that community-led HIVST was effective, safe, and affordable, with population impact and coverage rapidly realised at low cost. This approach could enable community HIV testing in high HIV prevalence settings and demonstrates potential for economies of scale and scope. Trial registration Clinicaltrials.gov NCT03541382., Author(s): Pitchaya P. Indravudh 1,2,*, Katherine Fielding 3,4, Moses K. Kumwenda 2, Rebecca Nzawa 2, Richard Chilongosi 5, Nicola Desmond 2,6, Rose Nyirenda 7, Melissa Neuman 3, Cheryl C. Johnson [...]

Introduction: In the era of ambitious HIV targets, novel HIV testing models are required for hard-to-reach groups such as men, who remain underserved by existing services. Pregnancy presents a unique opportunity for partners to test for HIV, as many pregnant women will attend antenatal care (ANC). We describe the views of pregnant women and their male partners on HIV self-test kits that are woman-delivered, alone or with an additional intervention. Methods: A formative qualitative study to inform the design of a multi-arm multi-stage cluster-randomized trial, comprised of six focus group discussions and 20 in-depth interviews, was conducted. ANC attendees were purposively sampled on the day of initial clinic visit, while men were recruited after obtaining their contact information from their female partners. Data were analysed using content analysis, and our interpretation is hypothetical as participants were not offered self-test kits. Results: Providing HIV self-test kits to pregnant women to deliver to their male partners was highly acceptable to both women and men. Men preferred this approach compared with standard facility-based testing, as self-testing fits into their lifestyles which were characterized by extreme day-to-day economic pressures, including the need to raise money for food for their household daily. Men and women emphasized the need for careful communication before and after collection of the self-test kits in order to minimize the potential for intimate partner violence although physical violence was perceived as less likely to occur. Most men stated a preference to first self-test alone, followed by testing as a couple. Regarding interventions for optimizing linkage following self-testing, both men and women felt that a fixed financial incentive of approximately USD$2 would increase linkage. However, there were concerns that financial incentives of greater value may lead to multiple pregnancies and lack of child spacing. In this low-income setting, a lottery incentive was considered overly disappointing for those who receive nothing. Phone call reminders were preferred to short messaging service. Conclusions: Woman-delivered HIV self-testing through ANC was acceptable to pregnant women and their male partners. Feedback on additional linkage enablers will be used to alter pre-planned trial arms. Keywords: HIV; rapid HIV test; HIV self-testing; financial incentives; ANC; Malawi; sub-Saharan Africa, Introduction Up to 54% of people with HIV in sub-Saharan Africa (SSA), the region hardest hit by the HIV epidemic, do not know their status [1]. The mortality rate in [...]