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HIV modelling and economic analyses have had a prominent role in guiding programmatic responses to HIV in sub-Saharan Africa. We reflect critically how the HIV modelling field might develop in future. We argue for HIV modelling to be more routinely aligned with national government and ministry of health priorities, recognizing their legitimate mandates and stewardship responsibilities, for HIV and other wider health programmes. We also place importance on an environment existing in which collaboration between modellers, and joint approaches to addressing modelling questions, becomes the norm rather than exception. Such an environment can accelerate translation of modelling analyses into policy formulation because areas where models agree can be prioritized for action, whereas areas over which uncertainty prevails can be slated for additional study, data collection and analysis. We also argue the need for HIV modelling to increasingly be integrated with the modelling of health needs beyond HIV, particularly in allocative efficiency analyses, where focusing on one disease over another may lead to worse health overall. Such integration may also enhance partnership with national governments whose mandates extend beyond HIV and to all of health care. Finally, we see a need for there to be substantial and equitable investment in capacity strengthening within African countries, so that African researchers will increasingly be leading modelling exercises. Building a critical mass of expertise, strengthened through external collaboration and knowledge exchange, should be the ultimate goal.

ObjectivesNon-communicable diseases (NCDs) account for one-third of disability-adjusted life years in Malawi, and access to care is exceptionally limited. Integrated services with HIV are widely recommended, but few examples exist globally. We report descriptive outcomes from an Integrated Chronic Care Clinic (IC3).DesignThis is a retrospective cohort study.SettingThe study includes an HIV–NCD clinic across 14 primary care facilities in the rural district of Neno, Malawi.ParticipantsAll new patients, including 6233 HIV–NCD diagnoses, enrolled between January 2015 and December 2017 were included. This included 3334 patients with HIV (59.7% women) and 2990 patients with NCD (67.3% women), 10% overall under age 15 years.InterventionsPatients were seen at their nearest health centre, with a hospital team visiting routinely to reinforce staffing. Data were collected on paper forms and entered into an electronic medical record.Primary and secondary outcome measuresRoutine clinical measurements are reported at 1-year post-enrolment for patients with more than one visit. One-year retention is reported by diagnosis.ResultsNCD diagnoses were 1693 hypertension, 668 asthma, 486 epilepsy, 149 diabetes and 109 severe mental illness. By December 2018, 8.3% of patients with NCD over 15 years were also on HIV treatment. One-year retention was 85% for HIV and 72% for NCDs, with default in 8.4% and 25.5% and deaths in 4.0% and 1.4%, respectively. Clinical outcomes showed statistically significant improvement for hypertension, diabetes, asthma and epilepsy. Of the 1807 (80%) of patients with HIV with viral load results, 85% had undetectable viral load.ConclusionsThe IC3 model, built on an HIV platform, facilitated rapid decentralisation and access to NCD services in rural Malawi. Clinical outcomes and retention in care are favourable, suggesting that integration of chronic disease care at the primary care level poses a way forward for the large dual burden of HIV and chronic NCDs.

The Malawian health sector has a strong tradition of systematic data collection for monitoring and evaluation of large-scale services. A highly successful adapted Directly Observed Treatment, Short course “DOTS” framework, based on patient registers and paper-based mastercards was introduced to facilitate the management and monitoring of the scale up of antiretroviral therapy. Subsequently, a simple, touch-screen based electronic medical record system (EMRs) was effectively introduced at high burden ART sites. Based on this model, in 2010, a diabetes specific EMRs was introduced in the diabetes clinic at Queen Elizabeth Central Hospital. In this paper we report on the first 3 years experience with the diabetes EMRs. We highlight the strengths and weaknesses of the diabetes EMRs and present data on glycaemic control recorded in the system.

Queen Elizabeth Central Hospital, Blantyre, Malawi.To determine 1) the proportion of human immunodeficiency virus (HIV) infected tuberculosis (TB) patients started on antiretroviral therapy (ART), 2) the timing of ART and 3) the effect of the timing on TB treatment outcomes.A retrospective record review of HIV-infected TB patients registered from January to December 2009.A total of 3376 TB patients were registered, of whom 2665 (79%) were HIV-tested and 2042 (77%) were HIV-infected. A total of 1190 HIV-infected TB patients who were not on ART at the time of starting TB treatment were studied. Of 688 (58%) who started ART, 61% started therapy within 2 months of anti-tuberculosis treatment and 39% started later (≥2 months). Treatment success for patients with TB who started ART within 2 months was higher than for those starting ART later (RR 1.6, 95%CI 1.4-1.8), and death rates were lower (RR 0.25, 95%CI 0.19-0.35).Under routine programme conditions in Malawi, a higher proportion of HIV-infected TB patients who started ART did so within 2 months of starting TB treatment, and early ART intervention was associated with better treatment outcomes. This confirms recommendations that co-infected TB patients should start ART early.Hôpital Central Reine Elisabeth, Blantyre, Malawi.1) Déterminer la proportion de patients tuberculeux infectés par le virus de l’immunodéficience humaine (VIH) mis sous traitement antirétroviral (ART), 2) le moment du début de l’ART et 3) l’effet du moment du début de l’ART sur les résultats du traitement antituberculeux.Revue rétrospective des dossiers des patients tuberculeux infectés par le VIH, enregistrés entre janvier et décembre 2009.Au total, 3376 patients ont été enregistrés, parmi lesquels 2665 (79%) ont été testés pour le VIH et 2042 (77%) étaient infectés par le VIH. On a étudié 1.190 patients TB infectés par le VIH qui n’étaient pas sous ART au moment du début du traitement de la TB ; 688 (58%) d’entre eux ont commencé l’ART et parmi ceux-ci, 61% ont commencé le traitement dans les 2 premiers mois du traitement anti-tuberculose et 39% ont commencé plus tard (Dans les conditions de routine du programme au Malawi, une proportion plus élevée de patients tuberculeux infectés par le VIH qui ont commencé l’ART l’ont fait au cours des 2 premiers mois du début de traitement de la TB, et les interventions ART précoces sont en association avec de meilleurs résultats du traitement. Ceci confirme les recommandations selon lesquelles les patients TB co-infectés devraient commence précocement l’ART.El hospital Queen Elizabeth Central de Blantyre, en Malawi.1) Determinar la proporción de pacientes con tuberculosis (TB) coinfectados por el virus de la inmunodeficiencia humana (VIH) que comenzaban el tratamiento antirretrovírico (ART); 2) registrar el momento del comienzo de este tratamiento; y 3) analizar el efecto de la simultaneidad de ambos tratamientos sobre el desenlace clínico de la TB.Se llevó a cabo un estudio retrospectivo de las historias clínicas de los pacientes tuberculosos coinfectados por el VIH entre enero y diciembre del 2009.Durante el período del estudio se registraron 3376 pacientes con TB y en 2665 de ellos (79%) se practicó la prueba serológica del VIH cuyo resultado fue positivo en 2042 casos (77%). Se estudiaron 1190 pacientes TB coinfectados por el VIH que aun no recibían ART al iniciar el tratamiento antituberculoso. Comenzaron ART 688 pacientes (58%), el 61% en los 2 primeros meses del tratamiento antituberculoso y el 39% lo comenzó más tarde (≥2 meses). El desenlace terapéutico de los pacientes tuberculosos que comenzaron el ART durante los 2 primeros meses fue más favorable que el desenlace de los pacientes que lo comenzaron más tarde (RR 1,6; IC95% 1,4–1,8) y presentaron una tasa de mortalidad más baja (RR 0,25; IC95% 0,19–0,35).En las condiciones corrientes del programa de Malawi, una mayor proporción de pacientes TB coinfectados por el VIH empezó a recibir ART en los primeros 2 meses de iniciado el tratamiento antituberculoso y esta intervención se asoció con un desenlace terapéutico más favorable. Este resultado respalda la recomendación de comenzar el ART de manera temprana en los pacientes que padecen además de TB.

Oxygen is a World Health Organisation listed essential drug yet provision of oxygen in developing countries often fails to meet demand. The aim of this study was to evaluate the need for supplementary oxygen against oxygen delivery capacity at a large teaching hospital in Malawi. A cross‐sectional study of all adult medical inpatients and assessment of oxygen provision over a 24‐hour period was conducted. 144 patients were included in the study, 14 of whom met local and international criteria for oxygen therapy (oxygen saturations of

More than 10 million metric tons of spent mushroom compost (SMC), which is a by-product of Agaricus bisporus mushroom, is produced in the world. Adding the compost to the soil resulted in improving the nutritional status of the plants. This study aims experiment is to study the effect of SMC on cucumber plant growth. A basic property of SMC and high concentrations of soluble salts restricted its implementation in the agricultural arena. The SMC was leached in order to reduce its salinity. Leached spent mushroom compost has less salinity while carbon and nitrogen content as well as inorganic cation components did not change significantly when compared to non-leached SMC. To study the effects of SMC on plant growth, leached SMC in rates of 15, 25, 35, and 45% were added to a sandy-loam soil medium. Cucumber plant growth rate was evaluated based on fruit number and plant height. Results showed that additions of 15% and 25% leached SMC to growing media significantly improved the cucumber plants growth.

Miguel Sanjoaquin and colleagues describe their experience of setting up an electronic patient records system in a large referral hospital in Blantyre, Malawi.

Advanced medical imaging technologies are generally unavailable in low income, tropical settings despite the reality that neurologic disorders are disproportionately common in such environments. Through a series of donations as well as extramural research funding support, an MRI facility opened in Blantyre, Malawi in July 2008. Resulting opportunities for studying common tropical disorders, such as malaria and schistosomiasis, in vivo are promising. The subsequent improvements in local patient care were expected and exceptional and include major revisions in basic care protocols that may eventually impact care protocols at facilities in the region that do not have recourse to MRI. In addition, advanced neuroimaging technology has energized the medical education system, possibly slowing the brain drain. Advanced technologies, though potentially associated with significant fiscal opportunity costs, may bring unexpected and extensive benefits to the healthcare and medical education systems involved.

Universal health coverage—defined as access to the full range of the most appropriate health care and technology for all people at the lowest possible price or with social health protection—was the goal of the 1978 Alma-Ata Conference on Primary Health Care in Kazakhstan. Many low-income (developing) countries are currently unable to reach this goal despite having articulated the same in their health-related documents. In this paper we argue that, over 30 years on, inadequate political and technical leadership has prevented the realization of universal health coverage in low-income countries.