Abstracts from the 2022 Kamuzu University of Health Sciences Research Dissemination Conference

O1.A001406.   LONG ACTING CABOTEGRAVIR: UPDATED EFFICACY AND SAFETY RESULTS FROM HPTN 084

Author(s): S. Delany-Moretlwe 1, J.P. Hughes 2, P. Bock 3, S. Dadabhai 4, D. Gadama 5, P. Hunidzarira 6, S. Innes 7, D. Kalonji 8, J. Makhema 9, P. Mandima 6, C. Mathew 1, J. Mpendo 10, P. Mukwekwerere 6, N. Mgodi 6, P. Nahirya Ntege 11, C. Nakabiito 12, H. Nuwagaba-Biribonwoha 13, R. Panchia 14, F. Angira 15, N. Singh 8, B. Siziba 6, E. Spooner 8, J. Farrior 16, S. Rose 16, R. Berhanu 1, Y. Agyei 17, S.H. Eshleman 17, M.A. Marzinke 17, E. Piwowar-Manning 17, S. Beigel-Orme 2, S. Hosek 18, A. Adeyeye 19, J.R. Rooney 20, A. Rinehart 21, B. Hanscom 2, M. Cohen 22, M. Hosseinipour 5,22, for the HPTN 084 study team

Affiliation(s):

1. University of the Witwatersrand, Wits RHI, Johannesburg, SA
2. Fred Hutchinson Cancer Research Center, Statistical Centre for HIV/AIDS Research and Prevention, Seattle, USA
3. University of Stellenbosch, Desmond Tutu TB Centre, Stellenbosch, SA
4. KUHeS, Johns Hopkins Research Project, Blantyre, Malawi
5. UNC Project-Malawi, Lilongwe, Malawi
6. University of Zimbabwe, Clinical Trials Research Centre, Harare, Zimbabwe
7. University of Cape Town, Desmond Tutu Health Foundation, Cape Town, SA,
8. South African Medical Research Council, HIV and other Infectious Diseases Research Unit, Durban, SA
9. Botswana Harvard AIDS Institute Partnership, Gabarone, Botswana
10. UVRI-IAVI, Entebbe, Uganda
11. Baylor College of Medicine Children’s Foundation Uganda, Kampala, Uganda
12. Makerere University, Johns Hopkins University Research Collaboration, Kampala, Uganda
13. Columbia University Mailman School of Public Health, Eswatini Prevention Center, Mbabane, Eswatini
14. University of the Witwatersrand, Perinatal HIV Research Unit, Soweto, SA
15. KEMRI, Kisumu CRS, Kisumu, Kenya
16. FHI 360, Durham, USA
17. Johns Hopkins University School of Medicine, Department of Pathology, Baltimore, USA,
18. Stroger Hospital of Cook County, Department of Psychiatry, Chicago, USA
19. National Institute for Allergy and Infectious Diseases, Division of AIDS, Washington DC, USA
20. Gilead Sciences, Foster City, USA,
21. ViiV Healthcare, Durham, USA,
22. University of North Carolina at Chapel Hill, Chapel Hill, USA    

Email: sufia@jhu.edu

Introduction: HPTN 084 is an ongoing, multisite, Phase-3 randomized, controlled trial that demonstrated the superiority of long-acting injectable cabotegravir (CAB) compared to daily oral TDF/FTC for HIV prevention in individuals assigned female at birth. The blinded trial was stopped after a planned review in November 2020. Participants were then unblinded and continued their original regimen pending open-label CAB.

Objectives: To report HIV infections in the 12-months following unblinding (detected through 12/31/21) by site, arm and central laboratory test result.

Methods:  We estimated cumulative HIV incidence for the combined primary blinded and 12-month unblinded period, by assigned study arm. Grade 2+ adverse events (AEs), injection site reactions (ISR), pregnancy incidence and outcomes are reported for the unblinded period.

Results: Twenty-three incident infections (3 CAB, 20 TDF/FTC) were detected in the 12-month unblinded period. Of these, two (1 CAB, 1 TDF/FTC) were deemed to have occurred during the blinded phase. Only one CAB case had ever received an injection. Cumulatively, 62 incident HIV infections (6 CAB, 56 TDF/FTC) were observed over 6626 person-years (HIV incidence 0.94%, 95% CI 0.72, 1.20). CAB superiority appears sustained (HR 0.11, 95% CI 0.05, 0.24). No new safety concerns were identified. For the unblinded period, 2.4% (32/1318) of the CAB group reported a Grade 2+ ISR. Overall, Grade 2+ AEs in this period were balanced by study group; 20% were related to study product (CAB 19%, TDF/FTC 21%). Two deaths in the CAB group were unrelated to study product. An additional 83 pregnancies (43 CAB, 40 TDF/FTC) occurred in the unblinded period (incidence 3.20%, 95% CI 2.56, 3.98). No congenital anomalies were reported.

Conclusions: Reductions in HIV incidence were sustained in the unblinded period. CAB continues to be superior to TDF/FTC for HIV prevention in individuals assigned female at birth.

O2.A001356. ANTIMICROBIAL RESISTANCE IN SUB-SAHARAN AFRICA: A ONE HEALTH PROBLEM? INSIGHTS FROM GENOMIC ANALYSIS OF COMMUNITY CARRIAGE EXTENDED SPECTRUM BETA-LACTAMASE PRODUCING ENTEROBACTERIACEAE FROM UGANDA AND MALAWI         

Author(s): Patrick Musicha1, Derek Cocker2, Fiona A Oruru3, Mathew A Beale4, Shevin Jacob5, Nicholas A Feasey6, Nicholas R Thomson7

Affiliations:

1. Malawi-Liverpool-Wellcome Research Programme, Kamuzu College of Health Sciences; Wellcome Sanger Institute; Liverpool School of Tropical Medicine.
2. Malawi-Liverpool-Wellcome Research Programme, Kamuzu College of Health Sciences; Liverpool School of Tropical Medicine.
3. Infectious Disease Institute, Makerere University.
4. Wellcome Sanger Institute.
5. Infectious Disease Institute, Makerere University; Liverpool School of Tropical Medicine.
6. Malawi-Liverpool-Wellcome Research Programme, Kamuzu College of Health Sciences; Liverpool School of Tropical Medicine.
7. Wellcome Sanger Institute; London School of Hygiene and Tropical Medicine.  

Email: pm13@sanger.ac.uk

Introduction: Antimicrobial resistance (AMR) is widely considered a one health problem, but this concept seems not to be supported by data emerging from high income countries. We present data from the DRUM (Drivers of AMR in Uganda and Malawi) study, which investigated transmission of extended spectrum beta-lactamase producing Enterobacteriaceae (ESBL-E) between humans, animals and the environment.

Methods: We sequenced 4020 whole genomes of ESBL-E from human stool, animal stool and the environmental samples, longitudinally collected at five sites in Malawi and Uganda. We performed phylogenetic analyses and clustering, in silico multilocus sequence and O-antigen typing (for K. pneumoniae), screened for AMR determinants and correlated these genotypes to sample location, ecological source and other factors.

Results: 3,149 genomes, including 2345 E. coli and 814 K. pneumoniae passed quality control. We found multiple lineages of ESBL E. coli and K. pneumoniae across isolates from both Malawi and Uganda. blaCTX-M-15 was the predominant ESBL gene in both E. coli (66.1%) and K. pneumoniae (86.6%) isolates. The genomic epidemiology of CTX-M-15 E. coli from Malawi was consistent with global CTXM-15 producing E. coli: sequence type (ST) 131 (12.2%) was the most common, followed by ST38 (7.8%) and ST3580 (5.6%). In contrast, ST10 was most common (8.9%) in Uganda, followed by ST1193 (4.6%). We identified 20 novel E. coli lineages with 5% of E. coli genomes (10.0% in Uganda and 2.8% in Malawi) untypable by MLST, an indication of unsampled diversity likely due to limited representation of African genomes. We found no significant association between clustering of isolates by lineage and sample source.

Conclusion: Our study represents the largest collection of ESBL-E genomes from sub-Saharan Africa in one study. We demonstrate that in this setting, animals and the environment are important reservoirs of human colonising ESBL-E, and provide support for one health AMR interventions.

O3.A001286.   A QUALITATIVE EXPLORATION ON STRATEGIES FOR IMPROVING UPTAKE OF POSTNATAL CARE SERVICES IN THYOLO MALAWI.   

Author(s): Alinane Linda Nyondo-Mipando1, Marumbo Chirwa1, Sangwani Salimu1, Andrew Kumitawa2, Jacqueline Nkhoma3, Tiyese Jean Chimuna3, Martin Dohlsten4, Bongani Chikwapulo5  

Affiliations:

1. Department of Health Systems and Policy, School of Global and Public Health, Kamuzu University of Health Sciences
2. Department of Epidemiology and Statistics, School of Global and Public Health, Kamuzu University of Health Sciences
3. UNICEF Malawi Country Office
4. Department of Maternal, newborn, child and adolescent health and ageing, World Health Organization, Geneva
5. Quality Management Directorate, Ministry of Health, Malawi

Email: lmipando@kuhes.ac.mw

Introduction: Although postnatal care services form a critical component of the cascade of care in maternal, newborn, and child health the uptake of the services has remained low worldwide. The rate of postnatal care uptake in Malawi is at 50%.  This study explored and prioritised the strategies for optimising the uptake of postnatal care services uptake in Thyolo, in Malawi

Methods: A qualitative descriptive study was conducted from July to December 2020 in Thyolo District, Malawi, and was followed by a nominal group technique in October 2021 to prioritise strategies for optimising uptake of PNC services. We conducted focus group discussions among postnatal mothers, fathers, Health care workers, elderly women, and grandmothers. We conducted in-depth interviews with Midwives, and Key health care workers.  We held a nominal group technique among postpartum women, men, midwives, Health Surveillance Assistants, clinicians and health managers to prioritise the main strategies for provision of PNC. All qualitative data were managed using NVivo and were analysed following a thematic approach.

Results: The strategies for optimising PNC services at the health system level include training of health providers; improving the clinic operations with attention paid to task-shifting, hours of operation, having appointment date reminders, linkage to care, and provision of free health passport books; having infrastructure for the services, and having services delivered near where end-users reside.  At the community level, the strategies include community awareness campaigns that consist of drama groups and health mentors, and male involvement.  Additionally, we found that the priority strategies include refresher training and improvement in the clinic operations especially on hours of operation, having appointment date reminders, and linkage to care.

Conclusion: Optimisation of postnatal care services will require implementation of strategies that are acceptable and relevant in the context where services are provided and community awareness is key.

O4.A001472. HIGH PREVALENCE OF DYSLIPIDAEMIA AMONG PATIENTS WITH DIABETES MELLITUS, HYPERTENSION, AND COMORBIDITY OF DIABETES MELLITUS AND HYPERTENSION AT A TERTIARY HOSPITAL IN SOUTHERN MALAWI     

Author(s): Kondwani Katundu1,2, Victoria Mukhula2, Tamara Phiri3,4, Chimota Phiri4, Florence Filisa5, Pascal Chipewa 1, George Chirambo1, 6, Mwapatsa Mipando1, 6, Henry Mwandumba1,2, Adamson Muula7, Johnstone Kumwenda3   

Affiliations:

1. Department of Biomedical Sciences, Kamuzu University of Health Sciences, Blantyre, Malawi
2. Malawi-Liverpool Wellcome Trust Research Project, Blantyre, Malawi
3. Department of Medicine, Kamuzu University of Health Sciences, Blantyre, Malawi
4. Department of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
5. Kamuzu Central Hospital, Lilongwe, Malawi
6. Blantyre to Blantyre Research Facility, Kamuzu University of Health Sciences, Blantyre, Malawi
7. Department of Community and Environmental Health, Kamuzu University of Health Sciences, Blantyre, Malawi 

Email: kkatundu@kuhes.ac.mw

Introduction: Dyslipidaemia drives the process of atherosclerosis, and hence a significant modifiable risk factor which adds additional risk for cardiovascular diseases (CVDs) in patients with hypertension and diabetes. In Malawi, the prevalence, screening and management of dyslipidaemia among patients with diabetes mellitus (DM) and hypertension is not known. 

Objective: This study aimed to investigate the prevalence, biochemical characteristics, screening and management practice for dyslipidaemia among patients with DM, hypertension, and both DM and hypertension at a tertiary teaching hospital in Southern Malawi, Africa.

Methods: This was a cross-sectional study. A total of 256 adult participants (DM=100); hypertension =100; both condition = 56) were included in the cross-sectional study in 2021. Medical data and anthropometric measurements were recorded. Blood samples were analysed for HbA1C and serum lipids. Associated risk factors for dyslipidaemia were assessed.

Results: Dyslipidaemia was prevalent in 58%, 55%, and 70% of participants with DM, hypertension, and both conditions. High low-density lipoprotein cholesterol (LDL-C) was the most common dyslipidaemia type in all participant groups. Participants with both diabetes and hypertension had 2.4 times (95% CI 1.2 – 4.6) increased risk of LDL-C dyslipidaemia than those with diabetes alone (p=0.02). Overweight or obesity, and age over 30 years were risks for dyslipidaemia in patients with DM alone (OR 1.3 (95% CI 1.1 – 1.6), p=0.04, and OR 2.2 (95% CI 1.2 – 4.7) (p<0.01) respectively. Overweight and obesity predicted LDL-C dyslipidaemia in hypertensive patients (OR 3.5 (95% CI 1.2 – 9.9) p <0.001). Poorly controlled hypertension was associated with a 1.8 times risk (95% CI 1.1 – 2.7) of dyslipidaemia in patients with both DM and hypertension (p<0.01). Less than 1% of the participants ever had a lipogram performed before the study and were on lipid-lowering therapy.

Conclusion: Dyslipidaemia with LDL-C derangement was highly prevalent, especially in individuals with both DM and hypertension, with poor screening and treatment for the dyslipidaemia. Screening and managing dyslipidaemia should be reinforced to reduce the risk of major cardiovascular events in this population at increased risk.

PLENARY SESSION 2 ABSTRACTS

O5.A001468.   FACTORS CONTRIBUTING TO LOW OR INCOMPLETE VACCINATION AMONG UNDER-FIVE CHILDREN IN URBAN AREAS IN MALAWI: A COMMUNITY-BASED CROSS-SECTIONAL STUDY

Author(s): Atupele Kapito-Tembo1,2, Glory Kabaghe1, Temwa Mzengeza3, Dennis Mwagomba3, and Mike Chisema3       

Affiliations:

1. Kamuzu University of Health Sciences, MAC – Communicable Diseases Action Centre
2. Kamuzu University of Health Sciences, Public health department, School of Global and Public Health
3. Malawi Ministry of Health Expanded Program on Immunisation Unit     

Email: atupelekapito@gmail.com

Introduction: In Malawi, evidence shows that vaccination coverage among under-five children is declining in the urban compared to the rural areas including data from Malawi demographic health surveys. There is a need to identify factors that are contributing to low or incomplete vaccination among under-five children in urban communities. Results would inform the development of targeted and effective interventions to improve vaccination in children in urban settings.

Objective: To identify factors contributing to low or incomplete vaccination among under-five children in urban areas in Malawi.

Methods: A community-based cross-sectional study using quantitative and qualitative methods was conducted in urban areas across Malawi. A multi-stage sampling approach was used. Eight urban areas were sampled and in each area, 2 health facilities were randomly sampled. In each facility, 11 under-five children who were under-immunised and 5 fully immunised were randomly sampled. Information on socio-demographics, immunisation status and factors affecting immunisation was collected. Eight focus group discussions (FGDs) with child caregivers were conducted. Bivariate and multivariate logistic regression were used to assess associations between immunisation and factors. Thematic analysis was conducted for qualitative data.

Results: A total of 177 under-immunised and 85 fully immunised children were enrolled. In bivariate analysis, under-immunisation was associated with: education status, source of income, level of satisfaction with services, church influence, knowledge of immunizations and schedule, and ability to attend under-five clinic monthly. In multivariate analysis, the odds of child being immunised was higher among child caregivers with: business as a source of income compared to full-time employment (OR=3.5,95%CI:1.5-8.1) and inability to attend under-five clinic monthly (OR=7.9,95%CI:2.6-24.1). During FGDs, the caregivers mentioned: having busy schedules, lack of information on newly introduced vaccines, vaccine side effects, religious beliefs and health systems factors like long waiting queues and vaccines stock-outs as the reasons contributing to children being under-immunised in the urban areas.

Conclusion: In Malawi, the child caregivers with under-immunised children in the urban settings are experiencing socio-economic and health systems challenges and issues which are contributing to low vaccination coverage. There is a need to design and implement strategies targeting the needs of urban communities.

O6.A001282.   HIGH UNTREATED HIV PREVALENCE AND HIGH SCHISTOSOMIASIS PREVALENCE DESPITE TREATMENT: FINDINGS FROM “CREATING DEMAND FOR FISHERMEN’S SCHISTOSOMIASIS HIV SERVICES” (FISH) CLUSTER-RANDOMIZED TRIAL IN MANGOCHI, MALAWI   

Author(s): Augustine Talumba Choko1*, Sekeleghe Kayuni2, Peter MacPherson1, 3, 4, Chimwemwe Kwanjo-Banda1, Anthony Butterworth1, and Elizabeth L. Corbett4

Affiliation(s):

1. Malawi Liverpool Wellcome Trust Clinical Research Programme (MLW), Blantyre, Malawi
2. Medical Aid Society of Malawi (MASM), Blantyre, Malawi
3. Department of Clinical Sciences, Liverpool School of Tropical Medicine
4. Clinical Research Department, London School of Hygiene and Tropical Medicine

Email: chimwemwe.kwanjobanda@gmail.com

Introduction: Prevalence of untreated HIV has fallen dramatically in sub-Saharan Africa. However, people living in fishing communities remain underserved by both HIV and schistosomiasis services. We investigated the prevalence of untreated HIV and schistosomiasis from an ongoing trial.

Methods: This abstract reports process and not trial data. Conventional HIV testing and self-testing was offered to fishermen via beach clinics. Treatment with Praziquantel without testing was offered to fishermen with urine microscopy at 4 weeks to ascertain the number of eggs per 10ml urine. Prevalence estimates for untreated HIV and schistosomiasis along with 95% confidence intervals (CI) were computed using the binomial exact method.

Results: A total of 2,870 fishermen completed two study visits at the beach clinic from 34 out of 45 trial clusters. Of these, the mean age was 35.1 years (standard deviation [SD]: 12.7) while the majority 2,019/2853 (70.8%) were married. Up to 1,268/2705 (46.9%) were illiterate. Prevalence of untreated HIV was 95/2,129 (4.5%; 95% CI: 3.6; 5.4%). Every additional year in age (years) was associated with 4% increased risk of having untreated HIV risk ratio (RR) 1.04 (95% CI: 1.03; 1.06), p<0.001. Compared to married fishermen the risk of having untreated HIV was lower in those who were not married RR 0.25 (95% CI: 0.11; 0.53), p<0.001. Up to 269/2,212 (12.2%, 95% CI: 10.8; 13.6%) fishermen had schistosomiasis despite receiving treatment. There was an inverse relationship between increasing age (years) and having active schistosomiasis RR 0.99 (95% CI: 0.98; 1.00), p=0.004. The risk of having active schistosomiasis was higher among unmarried fishermen compared to fishermen who were married RR 1.31 (95% CI: 1.02; 1.67), p=0.036.

Conclusion: Despite HIV testing and schistosomiasis treatment being free we found very high untreated HIV and active schistosomiasis among fishermen. Better and early delivery of interventions in hard-to-reach groups such as fishermen are recommended.

O7.A001509. ADDRESSING NUTRITION KNOWLEDGE GAP IN AN INTEGRATED RMNCH/ECD PROJECT: EXPERIENCES OF MOTHERS2MOTHERS MALAWI    

Author(s): Tendai Mayani1, Yolande Baker2, and Bridget Malewezi1           

Affiliation(s):

1. mothers2mothers, Lilongwe, Malawi;
2. mothers2mothers, Cape Town, South Africa      

Email: Bridget.Malewezi@m2m.org

Introduction: 46% of the Malawian population is under 15, including 2.8 million children under five. Children often suffer from micronutrient deficiencies, which include anemia and zinc deficiency. Stunting is at 37.1%, and children living in rural Malawi are more affected. (UNICEF, July, 2018). MDHS 2015-16 indicates that infant and young child feeding practices are still low, only 25% of children aged 6–23 months meet their minimum dietary diversity, 29% meet their minimum meal frequency and 8% have a minimum acceptable diet).

Methods: Nutrition Facilitators (NF) were deployed to integrate nutrition in existing RMNCH/ECD projects in communities in Lilongwe district. NFs conducted mapping, pre-test assessment, delivered modular sessions with practical cooking demonstrations, established sustainable backyard gardens, and then conducted post-test assessment. Knowledge levels of 2,253 clients who were registered before and after undergoing modular sessions was uploaded on digital platform and analysed using Strata version 16.

Results: Of the 32 parameters assessing nutritional knowledge, majority (n=30) showed significant differences (p <0.05) between pre and post tests scores suggesting improvement in participant’s knowledge across the various thematic areas such as breastfeeding, infant feeding, effects of HIV on nutritional needs, nutritional supplementation during pregnancy & an improved understanding of adolescents, pregnancy and their nutritional needs. Areas where participants remained unclear and scored lower during post test assessment included whether HIV infection increases energy and nutritional needs as well as whether deworming is a strategy for anaemia control. 

Conclusion: Nutrition information can be integrated in maternal and child health programmes thus providing mothers and caregivers access to proper feeding practices of children for optimal growth.

O8.A001371. NURSE-EDUCATORS’ SELF-PERCEPTIONS IN A BSN PROGRAMME IN MALAWI: A MIXED-METHODS STUDY  

Author(s): Evelyn Chilemba1           

Affiliation(s):

1. Kamuzu University of Health Sciences, Malawi

Email: evelynchilemba@kuhes.ac.mw

Introduction: Nurse educator’s self perceptions efficacy of their teaching is key promoting learning experiences among students. Thus, nurse educators must be mindful of how their teaching tasks bring about change or transformation to their students pre existing knowledge base. To this end, the preliminary reviews and analysis in the learning processes of the BSN primed nurses at KUHES indicate a learning dissonance as the reason for the underperformance among graduate nurses. To bring about educational reform, nurse educators need to be aware of how traditional teaching methods impact their students learning experiences.

Objectives: To examine nurse educators perspectives of the processes, tools, strategies and approaches of the learning experiences among graduate nurses

Methods: Sequential mixed method design was instrumental in guiding the formulation of interview questions from the quantitative data thus, the data with significance to the nurse educators perceptions guided the conduct of in depth interviews. A sample of ten nurse educators utilizing purposive sampling participated interviews. Content analysis was used for analysing data to generate themes. Narrative generated a rich source of information about the nurse educators perceptions of and attitudes towards teaching and learning experiences.

Results: The educators self perceptions comprised five constitutive themes of “”educators”” teaching styles, “”teaching them to think”” “”resources for teaching”” “”student learning environment”” and “”strategies for improving learning to practice””. The results report the teacher centered approach was advanced where educators preferred teaching methods that depends on students numbers in class, teaching content, and the scheduled time for teaching. This is because educators believed that student learning during classroom teaching was an educators responsibility, and thus chose teacher centered approaches. Teacher centered approaches are less effective in creating opportunities for learners to reflect and become self directed in practice.

Conclusion: Teacher centered approaches are less effective in creating opportunities for learners to reflect and become self directed

O9.A001293. PREVALENCE OF SEXUALLY TRANSMITTED INFECTION IN PREGNANCY AND THEIR ASSOCIATION WITH ADVERSE BIRTH OUTCOMES; A CROSS-SECTIONAL SURVEY AND CASE-CONTROL STUDY AT QUEEN ELIZABETH CENTRAL HOSPITAL, BLANTYRE, MALAWI 

Author(s): Charlotte van der Veer1,4, Chifundo Kondoni1, Annie Kuyere1, Fatima Mtonga1, Vita Nyasulu1, George Shaba1, Chelsea Morroni2, Gladys Gadama3, Luis Gadama3, Kondwani Kawaza3, Queen Dube3, Neil French4, David Lissauer1,4, Bridget Freyne1  

Affiliation(s):

1. Malawi-Liverpool-Wellcome Trust Clinical Research Programme
2. Botswana Harvard AIDS Institute Partnership
3. Queen Elizabeth Central Hospital, Blantyre, Malawi
4. University of Liverpool, Department of Children’s and Women’s Health

Email: cvanderveer@mlw.mw

Introduction: There is limited data on the epidemiology of sexually transmitted infections (STIS) and their contribution to adverse birth outcomes in Malawi. As common STI are curable, their effect on birth outcomes is highly modifiable.

Methods: We recruited pregnant women at delivery at Queen Elizabeth Central Hospital, Blantyre, Malawi between August 2021 and May 2022. A composite case definition for adverse birth outcome (ABO) included stillborn, preterm, and low birth weight (LBW) infants and infants admitted to NICU within 24 hours of birth. The next born healthy term infant was recruited as control. Multiplex PCR was performed on maternal vaginal swabs for Neisseria gonorrhea (NG), Chlamydia trachomatis (CT), and Trichomonas vaginalis (TV). HIV and syphilis status was determined on maternal and infant serum. For syphilis, we used DPP point-of-care tests and confirmed with Rapid Plasma Reagin tests.

Results: We included 256 cases and 254 controls. Overall, we observed a maternal positivity rate of 3.1%, 2.7% and 17.1% for NG, CT and TV, respectively, and 16.5% and 17.6% seropositivity for HIV and syphilis respectively. Maternal syphilis seropositivity was significantly associated with LBW (p=0.030) and having both treponemal and non-treponemal antibodies, indicative of active disease, was associated with stillbirth (p=0.045). 25.8% of syphilis exposed live infants tested seropositive for both treponemal and non-treponemal antibodies. Four live infants met the clinical diagnosis of congenital syphilis. NG positivity associated with ABO (p=0.039), but no associations were observed for TV or CT with LBW, prematurity, stillbirth, NICU admission or ABO overall. Co-infections were common, mainly HIV/syphilis (n=25/510; 4.9%), HIV/TV (n=17/510; 3.3%) and NG/syphilis (n=6/510; 1.2%). Compared with health passport records, we detected 66 new syphilis diagnoses and 1 new HIV diagnosis.

Conclusion: Our study provides estimates for STI prevalence among pregnant women in Malawi and underscores the need for antenatal STI screening.

MALARIA EPIDEMIOLOGY, PREVENTION & TREATMENT ABSTRACTS

O10.A001399. TWENTY YEARS OF MALARIA CONTROL IN MALAWI: GEOSTATISTICAL ANALYSIS OF THE CHANGING MALARIA PREVALENCE IN MALAWI       

Author(s): Donnie Mategula1,2,3. Michael Give Chipeta1, Austin Gumbo2, Michael Kayange2, Dianne Janette Terlouw1,3   

Affiliation(s):

1. Malawi-Liverpool Wellcome Programme, Malawi
2. National Malaria Control Programme
3. Liverpool School of Tropical Medicine    

Email: dmategula@mlw.mw

Introduction: Malaria remains a public health problem in Malawi and has a serious socio-economic impact on the Malawian population.  Malaria is responsible for 25% of all outpatient visits and 37% of hospitalizations. In the past two decades, available malaria control tools have been substantially scaled up, such as insecticide-treated bed nets, artemisinin-based combination therapies, and more recently, the introduction of the malaria vaccine, the RTS, S/AS01.

Objective: To describe the epidemiology of malaria for the last two decades in order to under the past transmission and set the scene for the elimination agenda.

Methods: A collation of parasite prevalence surveys conducted between the years 2000 and 2021 was done A spatio-temporal geostatistical model was fitted to predict the yearly malaria risk for children aged 2–10 years PfPR 2–10) at 1×1 km spatial resolutions. Parameter estimation was done using the Monte Carlo maximum likelihood methods. District level prevalence estimates adjusted for population are calculated for the years 2006, 2010, 2012, 2014, 2017 and 2021

Results: There was a total of 2387 sampled unique locations from 2000 to 2021 that were identified through the data collation exercise. This represents 61,542 individuals that were sampled in the period. In general, the   PfPR2_10 was declining over the 21 years. The mean modelled national PfPR2_10 in 2006 was 13.92(95CI:7.18-23.62) and declined to 8.3(95%CI4.37 to13.99). The smoothened estimates of PfPR2_10 indicate that malaria prevalence is very heterogeneous with hotspot areas concentrated on the southern shores of the lake.

Conclusions: The last two decades are associated with a decline in malaria prevalence, highly likely associated with the scale up of control interventions. The country should move towards targeted approaches of malaria control informed my surveillance data

O11.A001445. INCIDENCE OF CLINICAL MALARIA, ACUTE RESPIRATORY ILLNESS, AND DIARRHOEA IN CHILDREN IN SOUTHERN MALAWI: A PROSPECTIVE COHORT STUDY        

Author(s): Tinashe A. Tizifa1,2, Alinune N. Kabaghe1,2 , Robert S. McCann2,3,4 , William Nkhono2 , Spencer Mtengula2 , Willem Takken 3 , Kamija S. Phiri2 , Michele van Vugt1

Affiliation(s):

1. Center for Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, University of Amsterdam, Amsterdam University Medical Center, location Academic Medical Center, Amsterdam, The Netherlands
2. School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
3. aboratory of Entomology, Wageningen University & Research, Wageningen, The Netherlands.
4. Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, USA   

Email: t.tizifa@amsterdamumc.nl

Introduction: Malaria, acute respiratory infections (ARIs) and diarrhoea are the leading causes of morbidity and mortality among under-five children. Estimates of the malaria incidence are available from a previous study conducted in southern Malawi in the absence of community-led malaria control strategies; however, the incidence of the other diseases is lacking, owing to understudying and competing disease priorities. Extensive malaria control measures through a community participation strategy were implemented in Chikwawa, southern Malawi from May 2016 to reduce parasite prevalence and incidence.

Objectives: Assessment of incidence of clinical malaria, ARIs and acute diarrhoea among under-five children in a rural community involved in malaria control through community participation.

Methods: A prospective cohort study was conducted from September 2017 to May 2019 in Chikwawa district. Children aged 6–48 months were recruited from a series of repeated cross-sectional household surveys. Recruited children were followed up two-monthly for 1 year to record details of any clinic visits to designated health facilities. Incidence of clinical malaria, ARIs and diarrhoea per child-years at risk was estimated, compared between age groups, area of residence and time.

Results: 274 out of 281 recruited children had complete results and contributed 235.7 child-years. Malaria incidence was 0.5 (95% CI (0.4, 0.5)) cases per child-years at risk, (0.04 in 6.0–11.9 month-olds, 0.5 in 12.0–23.9 month-olds, 0.6 in 24.0–59.9 month-olds). Incidences of ARIs and diarrhoea were 0.3 (95% CI (0.2, 0.3)), (0.1 in 6.0–11.9 month-olds, 0.4 in 12.0–23.9 month-olds, 0.3 in 24.0–59.9 month-olds), and 0.2 (95% CI (0.2, 0.3)), (0.1 in 6.0–11.9 month-olds, 0.3 in 12.0–23.9 month-olds, 0.2 in 24.0–59.9 month-olds) cases per child-years at risk, respectively. There were temporal variations of malaria and ARI incidence and an overall decrease over time.

Conclusion: In comparison to previous studies, there was a lower incidence of clinical malaria in Chikwawa. The incidence of ARIs and diarrhoea were also low and decreased over time. The results are promising because they highlight the importance of community participation and the integration of malaria prevention strategies in contributing to disease burden reduction.

O12.A001067.  MEASURING OUTDOOR BITES OF TWO MAJOR MALARIA VECTORS IN MALAWI   

Author(s): Fred Sande1, Martin Chiumia1, Charlotte Banda1, Lusungu Chamdimba1, Ganizani Kapito1, Medson Kamwana1, Leonard Dandalo2, Don Mathanga1 and Themba Mzilahowa1

Affiliation(s):

1. Malaria Alert Centre-Communicable Disease Action Centre
2. Abt Associates, U.S President’s Malaria Initiative – VectorLink Project, Malawi    

Email: fsande@mac.kuhes.ac.mw

Introduction: Malaria is endemic in Malawi. Indoor residual spraying (IRS) and long-lasting insecticidal nets (LLINs) are the core interventions to control malaria in the country. These tools have been attributed to reduction of malaria transmission. However, in recent years there has been a plateau in the control progress. Therefore, this study investigates outdoor vector biting behavior that are sustaining malaria transmission in Malawi. 

Methods: Seven study villages across six districts of Malawi were sampled quarterly from July 2021 to June 2022. Adult mosquitoes were collected using Human Landing Catches (HLCs) from 5:00 pm to 11:00 am. Six households from each village were selected for a single night of collection per quarter.

Results: A total of 1,827 female Anopheles mosquitoes was collected. Out of these, 58.8% (n=1,072) were Anopheles funestus s.l and 41.2% (n=752) were Anopheles gambiae s.l. with outdoor/indoor ratio of 0.5 and 2.2 respectively. Biting activity was observed throughout the night in both species. Overall, human biting rate for Anopheles gambiae s.l. outdoors (3.5 bites/person/night) were higher than indoors (1.6 bites/person/night).

Conclusion and recommendations: Anopheles gambiae s.l. predominantly fed outdoors. However, the current vector control tools primarily target endophagic and endophilic anophelines which may not be sufficient. Therefore, outdoor control tools should be explored to supplement the existing ones.

O13.A001461.  FACTORS SHAPING INDIVIDUAL NIGHT TIME EXPOSURE TO MALARIA TRANSMISSION IN MALAWI: CASE OF CHIKWAWA DISTRICT        

Author(s): Lusungu Kayira1, Federica Guglielmo2, Eleanor MacPherson2,3, Themba Mzilahowa1, and Blessings Kaunda-Khangamwa1,4

Affiliation(s):

1. Kamuzu University of Health Sciences, Malaria Alert- Communicable Diseases Action Centre, Malawi
2. Liverpool School of Tropical Medicine, Liverpool, United Kingdom
3. Malawi-Liverpool-Wellcome Trust, Blantyre, Malawi
4. School of Public Health, University of the Witwatersrand, Johannesburg, South Africa

Email: lkayira@mac.medcol.mw

Introduction: The continuous interaction between the malaria vector, the individual host, and the society, results in persistent malaria transmission despite the provision of bed nets. Changes in mosquito behaviours from indoor to outdoor biting also contribute to ongoing malaria risks due to varied outdoor activities in homes, and recreational and social-cultural gatherings.  This required a detailed understanding of who, when, and how individuals will be outdoors at night exposed to malaria vectors.

Methods: This was an explorative qualitative study. Convenience sampling was used to identify twenty community members living within the reach of the researcher for participant observations with, twenty in-depth-interviews and four focus group discussions in Chikwawa.  We recorded adults and youth above 18 years’ day-to-day activities and interactions between 1800-0600 for six weeks. A thematic analysis was conducted to identify key themes. The social-ecological model helped to understand factors influencing exposure to mosquito bites and malaria transmission.

Results: Community members were found outdoors during the night due to social-cultural, economic, recreational, and environmental factors. Women were outdoors for social and community responsibilities – cooking, attending social functions, including economic reasons, and selling farm produce to traders. Some men were outdoors guarding their farms, especially during harvesting season while others visited bars at night, thereby exposing themselves to mosquito bites. Couples went to the farms as early as 4am; tended to businesses, eat supper outdoors after 6pm, while other families chatted till after 9pm, waiting for the night to become cooler to sleep. Children played the night away from home and watched movies at video shows.

Conclusion: Social and economic responsibilities and recreational factors expose adults and youths to mosquito bites. Given the variations in social contexts and experiences, community understanding of outdoor malaria transmission is critical for the development of human-centred and integrated vector control interventions.

O14.A001336.  ASSESSING THE PREFERRED RESTING SITES OF ANOPHELES MOSQUITOES INSIDE HOUSES IN CHIKWAWA DISTRICT, MALAWI 

Author(s): Banda JS1, Kambewa, E. A1, Kaunde N1, Jones CM2,3, Reimer L3, Olanga EA1, and Mzilahowa T1 

Affiliation(s):

1. Malaria Alert Centre, Kamuzu University of Health Sciences, Blantyre, Malawi
2. Malawi-Liverpool-Welcome Trust Research Program, Blantyre, Malawi
3. Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, United Kingdom

Email: jubanda@mac.kuhes.ac.mw

Introduction: Malaria vector control relies on long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS) in Malawi. IRS targets mosquitoes that rest on the inside walls of dwelling structures. However, there is lack of information regarding mosquito resting behaviours inside houses. The study assessed the resting behaviours and identified the preferred resting surfaces of mosquitoes inside three common house types in Chikwawa district.

Methods: Mosquito collection was done inside 80 houses across four villages (20 thatch roofed with mud walls, 20 thatch roofed with un-plastered brick walls, and 20 iron sheet roofed with un-plastered brick walls) between August and November 2020. In each house, resting mosquitoes were sampled from multiple surfaces (roofs, walls above 1m, and walls below 1m, floors, furniture, and clothing) from 6–8 AM using Prokopack aspirators

Results: A total of 5226 female Anopheles mosquitoes were captured of which Anopheles funestus s.l. (n=3423; 65.4%) was predominant followed by An. gambiae s.l. (n=1792; 34.2%). Blood-fed mosquitoes accounted for majority of Anopheles mosquitoes captured, regardless of house type (53% – 62%). An. funestus mosquitoes were twice as likely to be found resting on the underside of roofs compared to other surfaces in grass-thatch roof mud wall (OR = 2.81, 95% CI 2.48 – 3.18, p=<0.001) and grass-thatch brick wall houses (OR = 2.26, 95% CI 2.03 – 2.56, p<0.001). A large proportion of vectors were also captured on the underside of iron roofs of brick wall houses (54 – 56%). Overall, <10% of Anopheles were found resting on non-sprayable surfaces (hanging clothes, furniture and floors).

Conclusion: Majority of malaria vectors rest on the underside of grass-thatched roofs followed by walls which underpins the application of insecticides on these surfaces. There is an opportunity to exploit this resting behaviour and earmark roofs as potential surfaces to deploy novel vector control tools.

015.A001316.  MALARIA VECTOR RESPONSE TO DIFFERENT INSECTICIDES IN MALAWI 

Author(s): M. Chiumia1, F. Sande1, L. Chamdimba1, G. Kapito1, C. Banda1, M. Kamwana1, L. Dandalo2, and T. Mzilahowa1   

Affiliation(s):

1. Malaria Alert Centre, P/Bag 360, Blantyre, Malawi
2. Malawi VectorLink Abt Associates, Lilongwe

Email: mchiumia@mac.kuhes.ac.mw

Introduction: Insecticide resistance particularly to pyrethroids has potential to compromise malaria vector control globally. In Malawi, high insecticide resistance to pyrethroids has been reported. We carried out Anopheles sp susceptibility tests against pyrethroid insecticides and new insecticides used in public health, clothianidin and chlorfenapyr in order to provide guidance to the national malaria control programme on choice of insecticides and products.

Methods: Blood-fed female Anopheles mosquitoes and larvae were sampled from Chikwawa, Salima, Kasungu, Karonga and Nkhotakota districts. WHO tube bioassays were used to test both An. funestus s.l. and An. gambiae s.l.  against deltamethrin 0.05%, permethrin 0.75%, PBO + permethrin 0.75%, alphacypermethrin 0.05%, and pirimiphos-methyl 0.25%. The CDC bottle bioassays were used to test resistance against clothianidin (4µg/bottle) and chlorfenapyr (100µg/bottle).

Results: In Chikwawa, An. gambiae s.l. was resistant to deltamethrin, permethrin and alphacypermethrin. However, it was fully susceptible to pirimiphos-methyl, chlorfenapyr and partially susceptible to clothianidin. Similarly, An. funestus s.l. remains fully susceptible to pirimiphos-methyl.  In Salima, An. gambiae s.l. was fully susceptible to clothianidin and pirimiphos-methyl, but resistant to alphacypermethrin (11.7% mortality, n=103), deltamethrin (34.6% mortality, n=105) and permethrin (33.3% mortality, n=102). In Kasungu, An. funestus s.l. were resistant to permethrin (15.5% mortality, n=103) but susceptible to PBO + permethrin (98.1% mortality, n=52) and pirimiphos methyl (98% mortality, n=54).  In Nkhotakota, An. funestus s.l. was resistant to alpha-cypermethrin (34% mortality, n=44) but remains susceptible to clothianidin (100% mortality, n=29). In Karonga, An. gambiae s.l. was susceptible to pirimiphos-methyl (100% mortality, n=111), clothianidin (100% mortality, n=107), and chlorfenapyr (98% mortality, n=94).

Conclusion: Malaria vectors were resistant to pyrethroids across all the study sites in Malawi. However, pre-exposure of An. funestus s.l. to PBO resulted in partial restoration of its susceptibility to permethrin. Therefore, the distribution of PBO-treated nets must be encouraged in Malawi. Additionally, pirimiphos methyl and clothianidin must be used for indoor residual spraying in the country.

HIV EPIDEMIOLOGY, PREVENTION & TREATMENT ABSTRACTS

O16.A001320. MALAWI’S PROGRESS TOWARDS THE UNAIDS 95-95-95 HIV TESTING AND TREATMENT TARGETS: COMPARISON OF THE 2015-16 AND 2020-21 MALAWI POPULATION-BASED HIV IMPACT ASSESSMENTS (MPHIA)   

Author(s): Nellie Wadonda1, Danielle Payne1, Alinune N. Kabaghe 1, Lyson Tenthani 2, Christina Braccio 3, Evelyn Kim 1, Mtemwa Nyangulu1, Andreas Jahn 4,6, Christine A. West3, Felix Kayigamba2, Francis M. Ogollah2, Andrew Auld1, George Bello4,6, Mansoor Farahani5, and Rose Nyirenda4       

Affiliation (s):

1. US Centers for Disease Control and Prevention, Malawi

2. ICAP at Columbia University, Malawi

3. US Centers for Disease Control and Prevention, Atlanta

4. Ministry of Health, Malawi

5. ICAP at Columbia University, New York

6. I-TECH, University of Washington, Seattle, USA

Email: ywb9@cdc.gov

Introduction: The 2015-16 Malawi Population-based HIV Impact Assessment showed notable coverage gaps in HIV diagnosis, antiretroviral therapy access and retention, and viral load suppression (VLS). Targeted interventions were implemented by the Government of Malawi, PEPFAR and other partners to close these gaps. The second MPHIA was conducted between January 2020 and April 2021 to measure progress towards the UNAIDS 90-90-90 goals. 

Methods: MPHIA is a nationally representative survey, which enrolled over 23,000 participants. Participants were interviewed and a blood sample was tested for HIV infection using the national algorithm. Results were returned to participants. All HIV positive samples were tested for viral load (VL) and presence of antiretrovirals (ARV); a suppressed VL was defined as <1,000 viral copies per milliliter. All results were weighted and self-reported awareness and treatment status were adjusted to account for ARV detection results. This analysis was restricted to participants aged 15-64 years with HIV test results.

Results: HIV prevalence decreased significantly from 10.6 % [95% confidence interval (CI): 9.9%-11.2%] in MPHIA 2015-16 to 8.9% (95% CI: 8.4%-9.5%) in MPHIA 2020-21. Awareness of HIV status among all adults increased from 76.8% (95%CI: 74.7%-79.0%) to 88.4% (95% CI: 86.7%-90.1%), with females increasing from 80.2% (95%CI: 77.8%-82.5%) to 90.4% (95%CI: 88.5%-92.2%). Among 15-24-year-olds, awareness increased from 53.7% (95%CI: 45.3%-62.0%) to 76.2% (95%CI: 69.4%-83.1%). Among all adults aware of their HIV status, ART use increased from 91.4% (95%CI: 89.8%-93.0%) to 97.8% (95%CI: 97.1%-98.5%). Viral suppression (VLS) among those on treatment increased from 91.3% (95% CI: 89.3%-93.3%) to 96.9% (95% CI: 96.0%-97.8%). Population VLS among all adults living with HIV increased from 68.3% (95%CI: 66.0%-70.7%) to 87.0% (95%CI: 85.4%-88.6%). However, VLS remained lowest in the major urban centers of Lilongwe and Blantyre cities, and among participants aged 15–24 years.

Conclusion: Targeted investments by district and subpopulation in HIV testing, ART linkage, adherence, and retention have resulted in significant progress towards achievement of the UNAIDS 90-90-90 targets. These results show that Malawi has exceeded the more recent UNAIDS 95-95-95 treatment and VLS targets. Continued targeted efforts and tailored interventions are needed to close remaining gaps, particularly among young people and in urban centers.

O17.A001085. TOWARDS ACHIEVING EPIDEMIC CONTROL, REVIEW OF MORTALITY RATES, AND TRENDS AMONG HIV-POSITIVE PATIENTS ON ANTIRETROVIRAL THERAPY IN MALAWI: A 2017–2021 RETROSPECTIVE FOLLOW-UP STUDY

Author(s): Geoffrey C Singini1, and Thulani Maphosa1      

Affiliation(s)

1. Elizabeth Glaser Pediatric AIDS Foundation      

Email: gsingini@pedaids.org

Introduction: Recently, Malawi made impressive progress to achieve the epidemic control targets. However, HIV- and AIDS-related mortality continues to be a major public health concern in the country. Thus, understanding the incidence and predictors of mortality among people living with HIV who are on antiretroviral therapy (ART) could help to improve care, treatment, and monitoring of patients living with HIV. Drawing on the recent developments about improving quality of care and health impact through innovative systems and technologies in Malawi under PEPFAR, we demonstrate the usability of data lake to understand mortality trends and associated factors among people living with HIV on ART between 2017 and 2021.

Methods: We conducted a retrospective longitudinal follow-up study on all people living with HIV who were on ART and in the electronic medical record systems from January 2017, to September 2021. Follow-up time was defined as the time between ART start and last ART visit. We censored at one year (for first year mortality incidence) and at five years (for five-year mortality incidence) after ART initiation. We used multivariable Cox regression to explore the association between mortality and sociodemographic characteristics among the patients on ART to two time periods: 2011-2016 and 2017-2021. We also fitted Kaplan-Meier curves to examine survival functions between different subgroups to explore differences in mortality trends. All tests were tested for statistical significance at p < 0.05 using Stata version 17.0 for analysis.

Results: Our analysis included 412,837 patients: 60.8 % were females and 62,392 (5.04%) died while on ART. For the deceased, the median age was 37.1 (se = 37.2) and median number of years on ART was 3.3 (se =3.3). The overall incidence rate (per 1,000 person years) was estimated as 0.475 (95% CI = 0.422–0.536), which decreased from 0.826 (95% CI = 0.720–0.948) to 0.159 (95% CI = 0.078–0.314) in 2017 and 2020 respectively. Increased mortality was observed in male patients from unadjusted HR = 2.4 (95% CI = 1.888-3.078) to adjusted HR = 6.824 (95% CI = 3.195-14.578). No significant changes were noted in hazards for tuberculosis (TB)-positive patients [unadjusted HR 9.09 (95% CI = 4.649-17.773) to adjusted HR = 6.49 (95% CI = 3.042-13.863)] and pregnant women [unadjusted HR = 0.312 (95% CI = 0.129-0.758) to adjusted HR = 0.524 (95% CI = 0.211-1.299)].

Conclusion: The mortality rate among people living with HIV on ART for the past five years in Malawi requires attention. Biological differences help in understanding mortality in these patients, with men experiencing high hazards. While efforts have been implemented to keep patients on ART and reduce mortality for TB-positive and pregnant women, more needs to be done. Further research is needed to explain these findings related to TB and pregnant patients on ART. These data may suggest the need for innovative interventions to monitor care and treatment for people living with HIV on ART that should consider patients’ biological, comorbidities, and demographic differences.

O18.A001220.  BARRIERS AND FACILITATORS TO IMPLEMENTING ADVANCED HIV DISEASE SCREENING AT RUMPHI DISTRICT HOSPITAL-MALAWI: A SEQUENTIAL EXPLORATORY STUDY     

Author(s): Brany Mithi1, Agatha Bula 2, Lester Kapanda 3, Fatsani Ngwalangwa1 and Evanson Sambala1

Affiliation(s):

1. Kamuzu University of Health Sciences

2. University of North Caroline UNC-Malawi

3. Elizabeth Glaser Pediatric AIDS Foundation

Email: branytitus@gmail.com

Introduction: One of the strategies for reducing AIDS mortality outlined in the Malawi National HIV Strategic Plan is scaling up screening for Advanced HIV Disease (AHD). However, the delivery of AHD screening package has met several implementation hindrances evidenced by low numbers of eligible clients screened for AHD. Understanding factors that influence AHD screening is necessary for a successful implementation.

Objective: This study investigated the barriers and facilitators to implementing the AHD screening package at Rumphi District Hospital, Malawi.

Methods: A sequential exploratory study was conducted using a deductive approach, guided by a consolidated framework of implementation research (CFIR). Interviews were administered to key healthcare providers (n=10), purposively selected from Antiretroviral Therapy (ART) clinic and Laboratory department. Quantitative data for newly HIV-diagnosed individuals (n=101) was extracted from ART records over two quarterly months (July –Dec, 2021).

Results: About 60.4% (n=61) of newly diagnosed HIV-positive clients were not screened for AHD using CD4 Cell count (p = 0.041). 10 CFIR constructs were found to significantly influence the implementation process. Major barriers included insufficient resources to support the expansion of AHD screening services, inadequately trained providers in screening sites, poor communication systems affecting work coordination and a long AHD screening pathway leading to clients loss to follow-up. Innovation relative advantage, external support and availability of internally appointed focal leaders emerged as major facilitators of implementation.

Conclusion: Using CFIR conceptual framework and mixed methods, we established that contextual barriers from the inner setting need special attention to improve execution of AHD screening package.

O19.A001278. UNDERSTANDING GAPS IN INDEX CASE TESTING CASCADE: EXPERIENCE FROM PARTNERS IN HOPE SUPPORTED HEALTH FACILITIES IN MALAWI   

Author(s): Khumbo Phiri1, Maria Sanena1, Eric Lungu1, John Songo1, Joep van Oosterhout1,2, Sam Phiri1, Kathryn Dovel1,2

Affiliation(s): 

1. Partners in Hope, Lilongwe, Malawi
2. Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California, USA.     

Email: khumbo@pihmalawi.com

Introduction: Index case testing (ICT) is critical to reaching the minority of people still unaware of their HIV status. Implementation challenges limit the impact of ICT in sub-Saharan Africa. We use programmatic data from Partners in Hope supported facilities in Malawi to identify gaps across the ICT cascade, and in-depth interviews (IDIs) to understand why these gaps exist.

Methods: ICT strategies were taken to scale in October 2020 at 48 facilites in two districts in Malawi, with a focus on testing sexual partners (SP) and biological children (BC) of individuals recently diagnosed with HIV or with viral load results >1000copies/ml. Programmatic ICT data from October 2020-January 2021 were reviewed from 48 facilities to assess outcomes across the ICT cascade. We conducted IDIs with a random subset of index clients, their contacts (SP and BC), and health care workers (HCWs) from four facilities who were >18 years old and engaged in ICT during the same time-period. We analyzed data using constant-comparison methods in Atlas.ti.v9.

Results: The largest gaps in the ICT cascade were: 1) not successfully tracing eligible contacts; and 2) low HIV-positivity rates among those tested. We analyzed 49 IDIs: 13 index clients, 21 contacts (13 SP, 8 BC), and 15 HCWs. Barriers to contact tracing were index clients giving inaccurate contact information due to fear of unwanted disclosure (especially for new or extra-marital partners), as well as due to poor counseling/lack of trust in HCWs, and lack of privacy at ICT screening locations. Transport challenges for HCWs hindered community tracing. Barriers to high HIV-positivity rates were testing BCs of men and testing non-eligible BCs who were easy to reach during home visits to increase test productivity.

Conclusion: Improving quality of counseling and privacy, facilitating tracing activities, and promoting fidelity of ICT protocols are key to success across the ICT cascade.

O20.A001512. ARE VENUE-BASED STRATEGIES THE TICKET TO THE LAST MILE IN HIV PREVENTION IN MALAWI?        

Author(s): Emmanuel Singogo1, Sharon S Weir2, Evaristar Kudowa1, Maganizo Chagomerana1, John Chapola1, Jessie K. Edwards2, Confidence Banda1, Gift Kawalazira3, Yohane Kamgwira3, Lucy Platt4, Brian Rice4, James Hargreaves4, and Mina Hosseinipour2 

Affiliation(s):

1. University of North Carolina Project -Lilongwe Malawi
2. University of North Carolina, Chapel Hill, North Carolina USA
3. Ministry of Health, Blantyre DHO, BPS Project
4. London School of Hygiene and Tropical Medicine

Email: emmsingo@gmail.com

Introduction: Blantyre District has the highest adult HIV prevalence in Malawi (17% overall; 22% in women) and the lowest viral suppression rate (60%).  We hypothesized that social venues patronized by people with high sexual partnerships rates could identify sub-groups currently missed. 

Objective: to compare HIV testing outcomes and characterize the clinic and venue populations.

Methods: We conducted cross-sectional bio-behavioral surveys of representative samples of individuals seeking care in government clinics (n=2313) and social venue patrons (n=1802) Jan-Mar 2022. Government clinics and venues were randomly sampled from urban and rural strata with oversampling of rural venues using sampling weights. We followed national protocols for rapid tests, recency and viral load testing.  Acute infections were identified by pooling dried blood spots.

Results: Compared to the clinic population, the venue population was more likely to: be male (68% vs 28%); aged >25 years (61% vs 51%); unmarried (62% vs 40%); drink alcohol daily (43% vs 8%); have more sexual partners in the last year (mean 16 vs 2); report a new sex partner in the past 4 weeks (42% vs 14%); and report transactional sex (52% vs 12%). HIV prevalence was higher among the venue population (19% vs 9%) but had similar viral suppression (78%).  At venues, factors associated with HIV infection include female sex (39% vs 10%); having a new partner in the past 4 weeks (28% vs 13%) and transactional sex (25% vs 13%). Clinic participants who visited venues were less likely to be virally suppressed than other PLHIV clinic participants (53% vs 81%).  Acute and recent infections were uncommon. 

Conclusion: Lower HIV prevalence and greater viral suppression suggests that Blantyre’s HIV epidemic is slowing. Outreach to venues with higher prevalence of unsuppressed infection and to young women may advance prevention goals.  Testing for acute or recent infection yielded few cases, questioning its value for surveillance.

O21.A001145. HOW DO I OPEN UP? EXPLORING FACTORS ASSOCIATED WITH COMPLETION OF INTENSIVE ADHERENCE COUNSELLING SESSIONS AMONG PATIENTS WITH HIGH VIRAL LOAD IN NENO        

Author(s): Jimmy Villiera1, Beatrice Matanje2, Chiyembekezo Kachimanga2, and Dimitri Suffrin2    

Affiliation(s):

1. Baylor College of Medicine Children’s Foundation-Malawi
2. Partners in Health-Neno  

Email: jimmyvilliera@gmail.com

Introduction: Globally, countries are working tirelessly to achieve the UNAIDS 95-95-95 treatment targets by 2030. Despite making great strides in improving HIV viral load (VL) testing capacity for treatment monitoring in the past decade, a limited number of patients with high VL complete intensive adherence counselling (IAC) sessions which delays follow-up VL testing, consequently, delaying clinical decision-making. This study explored factors associated with the non-completion of IAC sessions.

Methods:  We conducted a mixed-method study. The quantitative data were collected from patient records from the period between 1 March 2020 to 30 June 2021 in Neno district, while qualitative data were collected from purposively selected clients (high VL) and healthcare workers, through focus group discussions (FGDs) and in-depth interviews respectively. 371 patient records were analyzed, while six heterogeneous FGDs of patients with high VL were conducted.  15 healthcare workers were also interviewed. STATA software was used to analyse quantitative data while thematic analysis approach was used for qualitative data.

Results: The median age of the participants at the most recent VL in the quantitative section was 39 years, IQR (31 – 47). The median age of respondents in FGDs was 41 with an interquartile range of 37 (20 – 57). Provider’s unprofessionalism, poor partner support, and lack of private rooms for conducting IAC sessions dissuaded clients to come for subsequent IAC sessions. Overall, we found that being on ART for a longer duration (p-value = 0.02) was significantly associated with the completion of IAC sessions and viral suppression. On multivariate analysis, we found that having community health worker support (ARR = 0.62; 95% CI = 0.39 – 0.99) and longer duration on ART (ARR = 1.76; 95% CI = 1.09 – 2.83) were significant predictors of IAC completion and subsequent viral suppression.

Conclusion: Clients with high VL encounter multiple challenges that affect IAC attendance. Although personal factors play a greater role in fulfilling IAC attendance, health system factors are equally important. ART Clinics need to devise deliberate and careful approaches that target and motivate at-risk clients to complete IAC sessions and improve overall adherence. There’s an urgent need for ART clinics to designate private rooms for IAC sessions and adequately train expert clients on professionalism.

MATERNAL & CHILD HEALTH 1 ABSTRACTS

O22.A001342. PERINATAL MORTALITY AUDITS AT QUEEN ELIZABETH CENTRAL HOSPITAL

Author(s): Tamanda Hiwa1  

Affiliation(s):

1. Department of Paediatrics and Child Health, Kamuzu University of Health Sciences   

Email: hiwatamie@gmail.com

Introduction: Clinical audits provide an opportunity for the review of care being provided to patients. They assess the quality of care being provided; whether it meets the required standards and explore areas of improvement. A collaboration between the Paediatrics Department and the Obstetrics and Gynaecology Department at QECH saw the genesis of perinatal mortality audits in the early 2000s with the shared goals of improved maternal and newborn outcomes and reduced perinatal mortality rate.

Objectives:

1. To describe the conduct of perinatal audits at QECH
2. To discuss challenges and lessons learnt from the audits

Methods: A monthly meeting patronised by departmental clinicians, nurses, hospital management, program partners and medical students is conducted. Presentations are prepared and delivered by postgraduate students. Data collection is continuous in the units throughout the month. The data is cleaned and analyzed separately by the two units using Microsoft excel. A case is selected for critique and discussion, based on the challenges identified with case management on either or both ends.

Results:  Multiple challenges have been identified. These include high rates of hypothermia at admission among inborn neonates (99%) and poor documentation in unit registers and charts. The audits have also brought about an improved working relationship between the two units evidenced by good communication, availability of the neonatal team at deliveries and a reduction in the neonatal mortality rate from 20% to 11%. Nursing staff now actively contribute to the discussions.

Conclusion: The forum paved the way for the Maternal and Perinatal Death Surveillance and Response team and the two units to collaborate with the ministry of health, reproductive health unit in exploring ways to adopt these audits and pilot them at other health facilities with the hopes for future national adoption of the activity.

O23.A001227.            PROCESSES AND OUTCOMES OF STILLBIRTH AND NEONATAL DEATH AUDIT IN MALAWI         

Author(s): Mtisunge Joshua Gondwe1,2, Mamuda Aminu3, Nicola Desmond2,3 and Stephen Allen1

Affiliation(s):

1. Liverpool School of Tropical Medicine, Clinical Sciences department
2. Malawi Liverpool Wellcome Trust Clinical Research Programme
3. Liverpool School of Tropical Medicine, Department of International Public Health

Email: mgondwe@mlw.mw

Introduction: Stillbirth and neonatal death audits are valuable tools for improving the quality of care and reduce mortality from preventable causes. Many interventions aimed at improving treatment do not achieve their desired change, with few efficiently implemented and sustained due to health system constraints.

Objectives: (1) To assess the resources available to support appropriate care for newborns, the quality of stillbirth and neonatal death audit processes and identified factors in implementing audit in Malawi. (2) To provide evidence for recommendations on how the health system may better support staff so that the audit process can be improved.

Methods: A mixed methods study, guided by a conceptual framework, conducted between August 2019 to December 2020 in seven public hospitals in the southern region of Malawi. We conducted facility resource survey, reviewed hospital surveillance data, audit documents, audited deaths and action plans. We assessed maternity and nursery ward staff perceptions about audit through 35 interview questionnaires and observed 12 audit meetings to assess quality of audits. We conducted 38 semi-structured interviews and seven focus group discussions with death audit committee members to identify factors affecting audit. Quantitative data was analysed using IBM SPSS 26.0 and presented using frequencies and proportions. Qualitative analysis was guided by a theoretical model and used a thematic analysis.

Results: We found that the hospitals’ ability to provide newborn care was universally low due to inadequate Infrastructure, staff training, medications and supplies, clinical protocols and leadership support. The quality of stillbirth and neonatal death audits was poor due to challenges in audit tools and guidelines, WHO audit cycle stages, action plans and patient load. Stillbirth audits were rarely done. We found that reported factors that affected audit at the individual, facility and national level were interrelated as they were informed by each other and were related to training, staff motivation, power dynamics and autonomy, audit meetings and data support.

Conclusion:  Audits may be supported more effectively by good facility, national leadership and resource management. Implementing suggested actions has potential to improve clinical outcomes. Given that the factors that facilitate or inhibit audits are interconnected, addressing challenges at only one level is unlikely to be adequate but a comprehensive approach that addresses factors at all system levels, recognising the relationships between levels, is more likely to be successful.     

O24.A001350. PERCEPTIONS ON THE ACCEPTABILITY OF THE 2016 WHO ANC MODEL AMONG THE PREGNANT WOMEN IN PHALOMBE DISTRICT, MALAWI – A QUALITATIVE STUDY USING THEORETICAL FRAMEWORK OF ACCEPTABILITY       

Author(s): Prince Nyumwa1,2* Agatha Kapatuka Bula3 and Alinane Linda Nyondo-Mipando1        

Affiliation(s):

1. Department of Health Systems and Policy, School of Global and Public Health. Kamuzu University of Health Sciences, P/Bag 360 Blantyre 3, Malawi.
2. Holy Family College of Nursing, P.O. Box 51224, Limbe, Malawi
3. University of North Carolina (UNC) Project, P/Bag A-104, Lilongwe, Malawi

Email: princenyumwa@gmail.com

Introduction:  The World Health Organization introduced a new model of care, ‘The 2016 WHO ANC Model’ to overcome challenges encountered during the implementation of Focused Antenatal Care Approach. For any new intervention to achieve its objective, it has to be widely accepted by both the deliverers and recipients of that intervention. Malawi rolled out the model in 2019 without carrying out acceptability studies.

Objectives: To explore the perceptions on the acceptability of the 2016 WHO ANC model among pregnant women in Phalombe District, Malawi.

Methods: We conducted a descriptive qualitative study between May and August 2021 at Phalombe Health Centre in Phalombe District. The study was guided byTheoretical Framework of Acceptability.We conducted 21 in-depth interviews (IDIs) among pregnant women, postnatal mothers, a safe motherhood coordinator, and Antenatal clinic midwives and two focus group discussions among Disease Control and Surveillance Assistants. All IDIs and FGDs were conducted in Chichewa, digitally recorded, and simultaneously transcribed and translated into English. Data were analysed manually using content analysis.

Results: The study found that the model is acceptable among most pregnant women and that some women were able to complete the new eight-contact schedule. The major enabling factors forthe acceptability of the model were the presence of support from husbands, peers, and health care providers. The major burdens were fatigue and increased transport costs that were associated with attending to the increased number of ANC contacts.

Conclusion: The study found that the model was acceptable among the pregnant women and that they were able to complete the new schedule. Therefore, reinforcing the enabling factors and increasing access to ANC services through conducting outreach clinics would help improve the acceptability of the model. There is also a need to increase knowledge among all the stakeholders involved.

O25.A001099. CHALLENGES AND OPPORTUNITIES IN THE INTRODUCTION OF MIDWIFE-LED ANTENATAL POINT-OF CARE ULTRASOUND SCAN IN BLANTYRE DISTRICT  

Author(s): Chipiliro Payesa1, Linly Seyama1, Sufia Dadabhai1, and Yankho Kanise1        

Affiliation(s):

1. John Hopkins Research Institute 

Email: cpayesa@jhp.mw

Introduction: Current WHO and Malawi antenatal care (ANC) guidelines recommend one ultrasound scan before 24 weeks of gestation. However, antenatal ultrasounds are not performed routinely in Malawi due to the lack of ultrasound devices and skilled providers. An ongoing study of the acceptability and feasibility of midwife-led ultrasound scans at health centres, using the Butterfly iQ point of care ultrasound (POCUS) has generated important knowledge for the future implementation of this service delivery model.

Objectives: To describe challenges and opportunities for implementation of midwife-led POCUS from the ARC-005 study

Methods: ARC-005 is a multi-phase, mixed-method, implementation research study in 10 rural, and urban health centres. Phase 1 trained 44 midwives on obstetric ultrasound using Butterfly iQ. Phase 2 involves an iterative approach to improving ANC service delivery, with an enrollment of 1500 ANC clients and Phase 3 will evaluate the program through stakeholders. For this analysis, we summarise the initial challenges and solutions from Phases 1 and 2.

Results:  Opportunities – 1500 obstetric scans have been conducted by midwives across the 10 health centres in the Blantyre district. Midwives are able to provide referrals to Queen Elizabeth Central hospital when they diagnose complicated pregnancies in their particular health centres Referral. Midwives are able to document in the health passports the findings of the ultrasound for continuity of care.

Challenges- Lack of skill with first-trimester scans due to the low patronage of first-trimester women at the ANC, midwives have not had a lot of experience in conducting the first-trimester scan. Waiting time for women: women spend extra time for the ultrasound service.

Conclusion: Robust implementation research can generate important data to inform service delivery and scale-up of ANC ultrasound at the national level. Ongoing mentorship and feedback to newly-trained midwives are needed to sustain ultrasound skills and achieve adequate quality scans.

A26.001369.   CHALLENGES EXPERIENCED BY NEWLY QUALIFIED NURSE-MIDWIVES TRANSITIONING TO PRACTICE IN SELECTED MIDWIFERY SETTINGS IN NORTHERN MALAWI    

Author(s): Mathews Brave Mtegha1*, Elizabeth Chodzaza2, Ellen Chirwa2, Fatch Welcome Kalembo3, and Maggie Zgambo4           

Affiliation(s):

1. Department of Nursing and Midwifery, St John’s Institute for Health, Mzuzu, Malawi
2. School of Maternal, Neonatal and Reproductive Health, Kamuzu University of Health Sciences, Blantyre, Malawi
3. School of Nursing, Curtin University, Perth, Australia
4. School of Nursing and Midwifery, Edith Cowan University, Perth, Australia

Email: mteghamathews3@gmail.com

Introduction: Literature shows that newly qualified nurse-midwives face challenges integrating into the workforce during their transition period from education to practice. However, little is known about the needs and challenges of Malawian nurse-midwives during their transition from education to practice.

Objectives: The aim of the study was to explore the transition experiences of newly qualified nurse-midwives working in selected midwifery units in Northern Malawi.

Methods: A qualitative descriptive approach was used. Data were collected through in-depth interviews using semi-structured interview guides from a purposive sample of 19 participants (13 newly qualified nurse-midwives and 6 key informants). The researchers developed two interview guides; one for the newly qualified nurse-midwives and another one for the key informants. The interview guides had questions related to newly qualified nurse-midwife’s experiences of transitioning to practise and the support they received. Participants were from three selected hospitals in the Northern part of Malawi that have maternity units. Data were analysed manually using thematic analysis.

Results: Five themes related to challenges faced by newly qualified nurse-midwives during their transition to practise in midwifery units emerged from the thematic analysis of the data. These included (1) Theory – practice gap, (2) Lack of confidence and skills, (3) Inadequate resources, (4) Transition support system, and (5) Workplace conflict.

Conclusion: Newly qualified nurse-midwives in Malawi encounter many challenges while transitioning from education to practice. The study findings underscore the need to develop a national framework support system that could not only help newly qualified midwives adjust positively to their new role but also create more opportunities for learning and developing and strengthening a collaborative partnership between colleges and hospitals.

HEALTH SYSTEMS & POLICY ABSTRACTS

O28.A001477. EVALUATING THE USABILITY AND ACCEPTABILITY OF IMPLEMENTING THE NATIONAL MATERNAL AND NEONATAL SURVEILLANCE PLATFORM FOR ESTABLISHING THE DIRECT AND INDIRECT EFFECTS OF COVID-19 IN MALAWI

Author(s): Moses Kumwenda1, Chikondi Chapuma1, Luis Gadama2, Fanny Kachale3, William Peno3, Deborah A. Phiri1, Lumbani Makhaza1, Andrew Likaka3, Rosemary Bilesi3, Malangizo Mbewe3, Owen Musopole3, Kondwani Kawaza2, Bertha Maseko1, Chifundo Ndamala1, Clemens Misesa1, Marc Henrion 1,4. James Chirombo1, Mercedes Bonet5, David Lissauer1

Affiliation(s):

1. Malawi Liverpool Wellcome Programme, Malawi, Kamuzu University of Health Sciences, Malawi
2. Kamuzu University of Health Sciences, Malawi
3. Ministry of Health, Malawi
4. Liverpool School of Tropical Medicine, Liverpool, United Kingdom
5. World Health Organisation
6. Malawi Liverpool Wellcome Programme, University of Liverpool, United Kingdom”  

Email: cchapuma@mlw.mw

Introduction and objective: To evaluate the usability and acceptability of implementing a novel maternal and neonatal COVID-19 surveillance system (MATSurvey) for capturing national-wide data on the direct and indirect effects of COVID-19 on Maternal and neonatal outcomes in Malawi.

Methods: A mixed methods process evaluation explored experiences during the implementation of the MATSurvey. A quantitative usability questionnaire was administered to 40 healthcare providers directly involved in the implementation of the system. Nine key informants and 14 healthcare workers were interviewed from four purposively selected health facilities (two high-performing and low-performing facilities). A deductive theme analysis using Proctor’s taxonomy of implementation outcomes was used.

Results: 85% of those who filled in the MATSurvey usability questionnaire thought it was easy to use. 87.5% were confident using it; 92.5% thought it was less cumbersome, and 80% thought it was less complex. 87.5% felt that various functions in the system were well integrated.  Qualitative data revealed that the surveillance platform was simple and acceptable to users. They expressed competency in using the platform and stated that utilisation of the information from the system to inform facility decision-making improved with time. The MATSurvey also addressed critical data management gaps linked to a paper-based system and allowed facilities to get feedback on their performance near real-time. Key barriers to the implementation included 1) technical challenges, such as poor internet connectivity and system downtime; 2) human resource problems, such as lack of training for new staff and increased human resource turnover; and data collection challenges, such as the difficulty to collect district-level data from peripheral health facilities.

Conclusion: The MATSurvey was acceptable, appropriate and usable among healthcare providers in Malawi. It also facilitated the delivery of care through timely, evidence-based decision making. However, the effective application requires overcoming technical and human resources challenges.

O29.A001415. NOVEL COMMUNITY-BASED RABIES SURVEILLANCE (CBRS) IN LILONGWE URBAN, MALAWI        

Author(s): Precious Innocent Mastala1,2*, Melaku Tefera1†, Edson Chiweta2, Madeline Nyamwanza2, Thoko Kapalamula1     

Affiliation(s):

1. Faculty of Veterinary Medicine, Lilongwe University of Agriculture and Natural Resources, Lilongwe, Malawi
2. Lilongwe Society for the Protection and Care of Animals, Lilongwe, Malawi      

Email: preciousmastala@gmail.com

Introduction: Rabies is a neglected tropical disease that is endemic to Malawi, killing almost 500 people every year. Domestic dogs are implicated as the main reservoir for rabies. However, there is limited capacity to detect canine rabies in the country, particularly in urban areas where there are high dog densities. The Lilongwe Society for the Protection and Care of Animals designed and implemented a canine community-based rabies surveillance (CBRS) in Lilongwe city between January and June 2020.

Objectives: To assess the effectiveness of the CBRS program in canine rabies detection compared to the traditional passive routine surveillance data of the years between 2015 and 2019. Furthermore, the study determined rabies Post-Exposure Prophylaxis (PEP) issuance trends in emergent cases.

Methods: Suspected canine rabies cases were recorded and followed. The dogs that were found alive were quarantined for 10 days for observation. Brain samples were collected postmortem for antigen detection using a direct-fluorescent antibody test.

Results: There were 610 suspected cases, and only 217 (39.2%) were followable. Out of these, 150 (62.8%) were followed. A total of 9 dogs (6%) tested positive, and there were 11 (7.3%) probable cases. This represents a 4.97-fold increase in detected rabies cases compared to the pre-surveillance period, with a resultant of 3.33 cases/month from 0.67 cases/month. There were 141 bite victims and 136 (96.5%) reported for PEP. Out of these, 89 (65.4%) were from healthy bites and 33 (24.4%) from suspect cases indicating a 63.1-87.6% rate of irrelevant PEP issuance. Exposed individuals were advised to seek PEP treatment immediately.

Conclusion: The CBRS program established relevance in increasing canine rabies detection and subsequent prevention of related human infections. It also established a high rate of PEP issuance following healthy bites. Therefore, we recommend enhanced multi-sectoral collaborative efforts aimed at increasing rabies detection and optimising PEP usage.

O30.A001409. PRIMARY PALLIATIVE CARE FOR THE OLDER POPULATION AND PATERNALISTIC MEDICINE: LESSONS FROM MANGOCHI, MALAWI          

Author(s): D Kwaitana1, D van Breevoort1, M Mnenula1, J Bates1, C. Evans2 K Nkhoma2, and R Harding2           

Affiliation(s):

1. Kamuzu University of Health Sciences, Department Family Medicine, Blantyre, Malawi  
2. King’s College London, Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute, London, UK.    

Email: dkwaitana@medcol.mw

Introduction: Ageing is a natural process, which presents a unique challenge to patients, families and health systems. WHO projects that by 2050, 80% of older people will be living in Low and Middle Income Countries (LMIC). Global successes in prevention and management of early childhood illness and safe motherhood pose a new health challenge to adequately meet healthcare needs of ageing patients and their families in light of increasing progressive multimorbidity. Keeping primary palliative care services available and accessible to the older patients is therefore vital to promote good quality of life.

Objectives: To assess whether healthcare needs and concerns of older people were discussed with service providers and considered in the management options.

Methods: In-depth qualitative interviews were conducted with n=15 older patients and family caregiver dyads with multimorbid illnesses attending primary care at Mangochi District Hospital and Lungwena Health Centre. Topic guides were developed and explored their experiences for primary palliative care services and how their needs were managed by healthcare professionals. Interviews were transcribed, translated, then analysed thematically using NVivo software.

Results: The majority of patients and caregivers were largely impressed with the care saying it improved the patients’ conditions. However, some participants indicated that their problems and concerns regarding care were not discussed with service providers because that opportunity was not made available for them.  Similarly, some caregivers stated that healthcare providers did not discuss with them about patients’ needs, but were quick to give advice on what they were supposed to do in caring for the patient at home. 

Conclusion: Practice of paternalistic medicine was reported as a common phenomenon among service providers in the primary care setting. Patients and caregiver problems and concerns were not always holistically assessed. Patient and family centred care is needed to achieve good palliative care.         

O31.A001157.  OVERCOMING OBSTACLES TO ACHIEVING GOOD ASTHMA CONTROL AMONG SCHOOL AGE CHILDREN IN BLANTYRE URBAN 

Author(s): Elizabeth Mkutumula1, Lovemore Nkhalamba1, Bernadetta Payesa1, Lusungu Sauli1, Annie Joabe1, Alberta Mukapita1, Beatrice Chinoko1, Jamie Rylance1,2, Gioia Mosler 4, Victoria Oluwatabi Oyenuga4, Jonathan Grigg4

Affiliation(s):

1. Malawi-Liverpool-Wellcome Trust, Malawi
2. Liverpool School of Tropical Medicine, UK 
3. Queen Elizabeth Central Hospital, Blantyre, Malawi
4. Queen Mary University of London, London UK

Email: emkutumula@mlw.mw

Introduction: Asthma prevalence has been shown to be increasing in urban areas. According to the ISAAC study, childhood asthma is the most common non-communicable childhood disease affecting 14% of children globally. A report by the Global Asthma Network sighted inadequacies in diagnosis, disease knowledge and management, as contributors to poor asthma control in African children. The knowledge gap in childhood asthma is a hindrance to implementation of population specific solutions in low-income countries. There is limited childhood asthma research in Malawi.

Objectives: To measure the burden of asthma among school age children, identify the barriers to achieving good asthma control, and explore ways to address identified barriers.

Methods: We screened students aged 12-14 years for wheeze and/or asthma symptoms. We obtained consent and collected core data from students who screened positive, using an electronic questionnaire, spirometry and exhaled nitric oxide (FeNO). Focus group discussions were completed with children, parents, and teachers, to further explore barriers to achieving good asthma control. We piloted a theatre intervention in schools and surrounding communities.  

Results: Preliminary data – 10,189 students from 35 Blantyre urban schools screened for wheeze in the last 12 months and/or asthma symptoms. 761 (7.5%) screened positive, with 52% reporting severe symptoms and 50% with no doctor confirmed asthma diagnosis. Core data collected from 213 students, objective airflow obstruction and/or airway inflammation noted in some who reported severe symptoms. Barriers to good asthma control included low asthma awareness/knowledge, undiagnosed symptoms, and limited access to care. 

Conclusions: Screening of school age children for asthma symptoms in combination with a school-based theatre intervention can be used to overcome some of the obstacles to achieving good asthma control through increasing asthma knowledge among children, teachers, and parents.

O32.A001358. HEALTH LEADERSHIP AND MANAGEMENT DEVELOPMENT IN MALAWI: TOWARDS A THEORY FOR HEALTH SYSTEMS STRENGTHENING    

Author(s): Thomasena O’Byrne1,2,6, Bongani Chikwapulo5, Kingsley Chikaphupha4, Linda Nyondo-Mipando7, Maryse Kok3, Marlen Chawani2, and Frédérique Vallières1           

Affiliation(s):

1. Centre for Global Health, Trinity College Dublin, Dublin, Ireland
2. Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
3. KIT Royal Tropical Institute, Amsterdam, the Netherlands
4. Research for Equity and Community Health (REACH) Trust, Lilongwe, Malawi
5. Quality Management Directorate, Ministry of Health and Population, Lilongwe, Malawi
6. Liverpool School of Tropical Medicine, UK
7. School of Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi  

Email: tobyrne@mlw.mw

Introduction: Strong leadership and management capacity of Human Resources for Health (HRH) is key to a health system’s performance. The current study sought to develop a framework for how health leadership and management is understood, can be further developed, and applied for HSS in Malawi, placing HRH at the centre of efforts.

Objectives: Offer an in-depth description of current leadership and management for health systems strengthening efforts in the context of Malawi.

1. To describe how key stakeholders conceptualise and understand health leadership and management in this context
2. To identify why health leadership and management approaches are being used to strengthen health systems within this context
3. To explore how the development of health leadership and management approaches are being implemented in practice

Methods: The study was informed by a qualitative case study methodology, drawing on the concepts and tools of grounded theory approaches, and using a soft-systems thinking lens. Four key methods were utilised, across a broad range of health-system stakeholders, including a documentary review of over 200 documents; in-depth interviews (n = 37); non-participant observation; and the development of rich pictures through systems mapping.

Results: Insights into values frontline stakeholders attach to effective leadership and management evidence a desire for approaches that are more relational and collectivistic, situated within a more psychologically safe and supportive working environment. Already overburdened district health teams faced unrealistic expectations as health leaders and managers. There was an identified desire for efforts to focus on developing health leadership and management at all levels of the health system, leveraging existing, yet often ignored, strengths and resilience at primary and community health care level.

Conclusion: For leadership and management development to contribute to HSS in Malawi, it must be aligned to the principles of systems thinking and applied faithfully system wide to enable people to better cope with their contexts.

O33.A001355. HARNESSING DATA SCIENCE RESOURCES TO ENHANCE CLINICAL STRATIFICATION OF INFECTIONS

Author(s): James Jafali1,2, Zahra Mungloo-Dilmohamud2,3 Dassen Sathan2,3, Sumir Panji 2,4, Christopher Fields2,5, Shakuntala Baichoo 2,3, Nicola Mulder2,3

Affiliation(s):

1. Malawi-Liverpool-Wellcome Trust, University of Liverpool
2. H3ABIONET
3. University of Mauritius
4. University of Cape Town, RSA
5. University of Ilinois, USA

Email: jjafali@mlw.mw

Introduction: Clinical stratification of bacterial and viral infections, which cause significant morbidity and mortality in low-and-middle-income-countries (LMICs), remains an outstanding public health challenge. Advances in Big-data science present powerful approaches such transcriptomic gene-signatures for enhanced diagnosis of diseases including cancer, infections, and autoimmunity. However, the existing gene-signatures are concentrated in high-income countries and lack robustness for wider applications in resource-limited settings.

Objective: To derive a robust gene-signature (using multiple data resources and rigorous approaches) for enhanced stratification of viral and bacterial infections.

Methods and results: Using a data-fusion approach involving multiple whole-blood transcriptome studies (n=1407) and a wide range of data science approaches; this analysis derived (n=1055, accuracy: 89%-93%) and validated (n=352, AUC: 93%-100%) a robust 18-gene transcriptomic signature for enhanced stratification of viral and bacterial infections. At the pathway level, this signature represents a cell-centred pro-inflammatory response involving an amplification of metabolic and myeloid immunity and a dysregulation of lymphoid (including NK-cells) and interferon pathways.

Conclusion: Together, these findings highlight an opportunity for robust diagnosis and optimal antibiotic treatment of bacterial infections in resource-limited and high-burden settings.           

SEXUAL & REPRODUCTIVE HEALTH ABSTRACTS

034.A001068.  BURDEN OF SEXUALLY TRANSMITTED INFECTIONS AMONG THE YOUTH IN RURAL MALAWI: A CROSS-SECTIONAL STUDY IN NENO DISTRICT  

Author(s): Justice Kachitsa1, 2, George C Talama2, Moses Banda Aron2, Fabien Munyaneza2, Chikondi Mchazime2, Rachel Mwanza2, Willy Chisindo3, Chiyembekezo Kachimanga2

Affiliation(s):

1. Kamuzu University of Health Sciences, Blantyre, Malawi
2. Partners in Health Malawi, Neno, Malawi
3. District Health Office, Ministry of Health and Population, Neno, Malawi      

Email:  jkachitsa@kuhes.ac.mw

Introduction: In Malawi, youths aged 15-24 years’ account for the majority of clients with sexually transmitted infections. Yet, the burden of sexually transmitted infections among the youth in rural settings remain unclear.

Objectives: To investigate the proportion of sexually transmitted infections and factors associated with sexually transmitted infection recurrence among youths 15-24 years in Neno, rural Malawi.

Methods: A cross- sectional study was conducted utilizing routinely collected sexually transmitted infections data in five primary care and two secondary care facilities. Multivariate logistic regression analysis was used.

Results: Of the 4,993 sexually transmitted infection clinic attendees, 37. 96% were youth aged 15-24 years. The mean age was 20.94 years (SD± 2.33 years). In females, abnormal vaginal discharge (high-risk) was the most commonly reported sexually transmitted infection syndrome, (47.2%). The proportion of HIV and sexually transmitted infection co-infection was higher in females (81.4%). Significant factors associated with STI recurrence included female gender [OR =1.29; 95% CI: 1.04 – 1.60, p= 0.022], age between 20-24 years [AOR =1.87; 95% CI: 1.47 – 2.37, p= <0.001] and being HIV negative [AOR =0.28; 95% CI: 0.21 – 0.39, p= <0.001].

Conclusion: We found a higher prevalence of sexually transmitted infections among the youth 15-24 years in rural Malawi, suggesting of the need to strengthen youth targeted behavior change interventions aimed at reducing risky sexual behaviors. Strengthening screening and treatment of sexually transmitted infection among the youth is also greatly encouraged in health facilities in rural settings. Youth living with HIV had high rates of sexually transmitted infections. These findings support the advocacy to strengthen integration of sexually transmitted infection screening and treatment with HIV services.

O35.A001097. INFLUENTIAL SOURCES OF KNOWLEDGE ON EARLY SEX ONSET AMONGST YOUTH IN BLANTYRE RURAL

Author(s): Gladson Makowa1, and Mary Kamwaza1          

Affiliation(s):

1. The Malawi University of Business and Applied Sciences (MUBAS), Blantyre, Malawi

Email: gladsonmkw@gmail.com

Introduction: Sexuality issues are taught in schools, youth clubs, initiation ceremonies and other media to prevent early sexual onset. But youths still have early sexual onset resulting in early pregnancies and high prenatal deaths. The aim of this study was to analyse sources of knowledge that influence early sexual onset among youths of Blantyre rural.

Objectives:

1. To examine major sources of sexual knowledge
2. To determine the information/knowledge that these sources give out
3. To establish sources that influence early sexual onset

Methods: Mixed research methods were used on a total sample of 222 with which individual and informants’ interviews, and focus group discussions were conducted. The study area was Mapazi, Chilaweni, Namikasi and Nankumba Blantyre Rural Secondary Schools.

Results: The study found that 100% learnt from school, 79.3% from peers, 67.7% from parents, 60% from television films, 48.8% from youth clubs. Out of 164 interviewed individually, 48.2% had sex, 82.1% sexed before the age of 18 and at 18 years 94.9 had sex and 81.3% used condoms. Those that had not initiated sex acknowledged parents, Church counselling, youth clubs and school as their dependable sources of knowledge and those that initiated sex acknowledged peers, pornographic films on television and the internet, traditional initiation, and radio adverts. Messages that delayed sex are; abstain to be righteous, moral, holy and have a bright future, sex outside marriage is a sin and threats from parents. Parents and teachers fail to replace peers as the most accessible sources because they are difficult to approach, not friendly. The peers are available and dependable source but mostly lack moral values and lead friends astray sexually. The television, internet and new media are full of pornography.

Conclusion: The recommendation is to provide dependable and accessible sources as their peers and that youth clubs should share economically bankable skills, not chats only.

O36.A001449. ASSESSING BARRIERS OF CONTRACEPTIVE UPTAKE AMONG ADOLESCENT GIRLS IN A RURAL DISTRICT OF MALAWI

Author(s): Sitalire Kapira1,2, Hannah Gilbert, Emilia Connolly1, Joan Kuffman2, Isaac Mphande1, Beatrice Matanje1, Chiyembekezo Kachimanga1, Anatole Manzi2, and Emily Wroe2

Affiliation(s):

1. Partners In Health/Abwenzi Pa Za Umoyo, Neno, Malawi, and Harvard Medical School, USA
2. Harvard Medical School, USA     

Email: sitalirekapira@ya