RESUMO
The DESIRE Study (MTN-035) explored product preference among three placebo rectal microbicide (RM) formulations, a rectal douche (RD), a suppository, and an insert, among 210 sexually active transgender people and men who have sex with men in five counties: the United States, Peru, Thailand, South Africa, and Malawi. Participants used each product prior to receptive anal sex (RAS) for 1 month, following a randomly assigned sequence, then selected their preferred product via computer assisted self-interview. In-depth interviews examined reasons for preference. We compared product preference and prior product use by country to explore whether geographic location and experience with the similar products impacted preference. A majority in the United States (56%) and Peru (58%) and nearly half in South Africa (48%) preferred the douche. Most in Malawi (59%) preferred the suppository, while half in Thailand (50%) and nearly half in South Africa (47%) preferred the insert. Participants who preferred the douche described it as quick and easy, already routinized, and serving a dual purpose of cleansing and protecting. Those who preferred the insert found it small, portable, discreet, with quick dissolution. Those who preferred the suppository found the size and shape acceptable and liked the added lubrication it provided. Experience with product use varied by country. Participants with RD experience were significantly more likely to prefer the douche (p = 0.03). Diversifying availability of multiple RM dosage forms can increase uptake and improve HIV prevention efforts globally.
RESUMEN: El estudio DESIRE (MTN-035) exploró la preferencia de producto entre tres formulaciones de microbicida rectal (MR) de placebo, una ducha rectal, un supositorio y un inserto, entre 210 personas transgénero y hombres que tienen sexo con hombres en cinco países: los Estados Unidos, Perú., Tailandia, Sudáfrica y Malawi. Los participantes utilizaron cada producto antes del sexo anal receptive (SAR) durante un mes, siguiendo una secuencia asignada al azar, luego seleccionaron su producto preferido mediante una autoentrevista asistida por computadora. Las entrevistas en profundidad examinaron los motivos de preferencia. Comparamos la preferencia de producto y el uso previo del producto por país para explorar si la ubicación geográfica y la experiencia con la forma farmacéutica impactaron la preferencia. Una mayoría en los Estados Unidos (56%) y Perú (58%) y casi la mitad en Sudáfrica (48%) prefirieron la ducha rectal. La mayoría en Malawi (59%) prefirió el supositorio, mientras que la mitad en Tailandia (50%) y casi la mitad en Sudáfrica (47%) prefirió el inserto. Los participantes que prefirieron la ducha rectal la describieron como rápida y fácil, ya parte de su rutina y que tenía el doble propósito de limpiar y proteger. Los que prefirieron el inserto lo consideraron pequeño, portátil, discreto y de rápida disolución. Los que prefirieron el supositorio encontraron que tenía un tamaño y forma aceptables y proveía lubricación adicional. La experiencia con el uso del producto varió según el país. Los participantes con experiencia con duchas rectales tenían significativamente más probabilidades de preferir la ducha rectal (p = 0,03). Diversificar la disponibilidad de múltiples formas farmacéuticas de MR puede aumentar la aceptación y mejorar los esfuerzos de prevención del VIH a nivel mundial.
Assuntos
Administração Retal , Infecções por HIV , Homossexualidade Masculina , Minorias Sexuais e de Gênero , Humanos , Masculino , Tailândia , Infecções por HIV/prevenção & controle , Malaui , Minorias Sexuais e de Gênero/psicologia , Estados Unidos , Adulto , Feminino , Adulto Jovem , África do Sul , Homossexualidade Masculina/psicologia , Supositórios , Adolescente , Peru , Preferência do Paciente , Comportamento Sexual , Pessoas Transgênero/psicologia , Anti-Infecciosos/administração & dosagem , Placebos/administração & dosagem , Formas de DosagemRESUMO
BACKGROUND: Maternal HIV infection remains a significant global health concern with potential repercussions on perinatal outcomes. Emphasis on early intervention to improve peri- and postnatal outcomes in infected mothers and infants is a valid therapeutic concern. OBJECTIVES: To comprehensively analyze perinatal outcomes associated with maternal HIV infection and evaluate adverse effects associated with the HIV infection in the existing literature. SEARCH STRATEGY: A comprehensive search of PubMed, MEDLINE, and Google Scholar was conducted from 2013 to September 2023, using relevant MeSH terms. SELECTION CRITERIA: The included studies encompassed original studies, cross-sectional, prospective, retrospective studies and observational studies focused on perinatal outcomes in the context of maternal HIV infection. DATA COLLECTION AND ANALYSIS: The selected studies underwent rigorous data collection and comprehensive quality checks and adhered to the PRISMA guidelines. MAIN RESULTS: Nine eligible studies from Brazil, China, India, Malawi, Nigeria, Tanzania, the USA, and Canada were included. These studies have consistently demonstrated that maternal HIV infection is associated with adverse perinatal outcomes. The analysis revealed a higher risk of preterm birth (OR 1.57, 95% CI: 1.39-1.78), low birth weight (OR 1.33, 95% CI: 1.18-1.49), and small for gestational age (OR 1.38, 95% CI: 1.24-1.53) among infants born to mothers living with HIV. Notably, the impact of antiretroviral treatment (ART) on these outcomes varied, but maternal HIV infection remained a significant risk factor regardless of income level and geographic region. CONCLUSION: Maternal HIV infection is consistently associated with adverse perinatal outcomes, emphasizing the need for targeted interventions and improved prenatal care in pregnant women with HIV infection.
Assuntos
Infecções por HIV , Complicações Infecciosas na Gravidez , Resultado da Gravidez , Humanos , Infecções por HIV/tratamento farmacológico , Infecções por HIV/complicações , Gravidez , Feminino , Recém-Nascido , Nascimento Prematuro/epidemiologia , Transmissão Vertical de Doenças Infecciosas/prevenção & controle , Recém-Nascido de Baixo Peso , Brasil/epidemiologia , Canadá , Recém-Nascido Pequeno para a Idade Gestacional , Índia/epidemiologia , China/epidemiologia , Nigéria/epidemiologia , Estados Unidos/epidemiologia , Tanzânia/epidemiologia , Malaui/epidemiologiaRESUMO
OBJECTIVE: To assess the association between breastfeeding competency, as determined by Latch, Audible swallowing, Type of nipple, Comfort, and Hold (LATCH) and Preterm Infant Breastfeeding Behavior Scale (PIBBS) scores, and exclusive breastfeeding and growth among infants with low birth weight (LBW) in India, Malawi, and Tanzania. STUDY DESIGN: We conducted LATCH and PIBBS assessments among mother-infant dyads enrolled in the Low Birthweight Infant Feeding Exploration (LIFE) observational study of infants with moderately LBW (1500g-2499 g) in India, Malawi, and Tanzania. We analyzed feeding and growth patterns among this cohort. RESULTS: We observed 988 infants. We found no association between LATCH or PIBBS scores and rates of exclusive breastfeeding at 4 or 6 months. Higher week 1 LATCH and PIBBS scores were associated with increased likelihood of regaining birth weight by 2 weeks of age [LATCH: aRR 1.42 (95% CI 1.15, 1.76); PIBBS: aRR 1.15 (95% CI 1.07, 1.23); adjusted for maternal age, parity, education, residence, delivery mode, LBW type, number of offspring, and site]. Higher PIBBS scores at 1 week were associated with improved weight gain velocity (weight-for-age z-score change) at 1, 4, and 6 months [adjusted beta coefficient: 1 month 0.04 (95% CI 0.01, 0.06); 4 month 0.04 (95% CI 0.01, 0.06); and 6 month 0.04 (95% CI 0.00, 0.08)]. CONCLUSION: Although week 1 LATCH and PIBBS scores were not associated with rates of exclusive breastfeeding, higher scores were positively associated with growth metrics among infants with LBW, suggesting that these tools may be useful to identify dyads who would benefit from early lactation support.
Assuntos
Aleitamento Materno , Recém-Nascido de Baixo Peso , Humanos , Aleitamento Materno/estatística & dados numéricos , Feminino , Estudos Prospectivos , Recém-Nascido , Masculino , Adulto , Lactente , Tanzânia , Índia , Malaui , Desenvolvimento Infantil/fisiologia , Estudos de CoortesRESUMO
BACKGROUND: Pregnancy represents a period of high HIV acquisition risk. Safety data for the monthly dapivirine vaginal ring (DVR) during pregnancy are limited. Here, we report data from the first 2 cohorts of pregnant participants in MTN-042/DELIVER, a phase 3b, randomized, open-label safety trial of DVR and oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC). MTN-042 is being conducted in 3 cohorts beginning with later gestational ages when risks of drug exposure are less. METHODS: Eligible pregnant individuals aged 18-40 years in Malawi, South Africa, Uganda, and Zimbabwe were randomized 2:1 to monthly DVR or daily TDF/FTC. Participants in cohort 1 initiated product use between 36 weeks 0 days (36 0/7 weeks) and 37 6/7 weeks gestation; participants in cohort 2 initiated product use between 30 0/7 and 35 6/7 weeks gestation. All participants continued product use until delivery or 41 6/7 weeks gestation. Pregnancy outcomes and complications were assessed and summarized using descriptive statistics and compared with local background rates obtained through a separate chart review. RESULTS: One-hundred and fifty participants were enrolled into cohort 1 with 101 randomized to DVR and 49 to TDF/FTC. One-hundred and fifty-seven participants were enrolled into cohort 2 with 106 randomized to DVR and 51 to TDF/FTC. In both cohorts, pregnancy complications were rare and similar to local background rates. CONCLUSION: In this first study of a long-acting HIV prevention agent in pregnancy, adverse pregnancy outcomes and complications were uncommon when DVR and TDF/FTC were used in the third trimester of pregnancy, suggesting a favorable safety profile for both prevention products.
Assuntos
Infecções por HIV , Feminino , Gravidez , Humanos , Infecções por HIV/prevenção & controle , Emtricitabina , Idade Gestacional , Malaui , Tenofovir/efeitos adversosRESUMO
Viral metagenomics has been extensively applied for the identification of emerging or poorly characterized viruses. In this study, we applied metagenomics for the identification of viral infections among pediatric patients with acute respiratory disease, but who tested negative for SARS-CoV-2. Twelve pools composed of eight nasopharyngeal specimens were submitted to viral metagenomics. Surprisingly, in two of the pools, we identified reads belonging to the poorly characterized Malawi polyomavirus (MWPyV). Then, the samples composing the positive pools were individually tested using quantitative polymerase chain reaction for identification of the MWPyV index cases. MWPyV-positive samples were also submitted to respiratory virus panel testing due to the metagenomic identification of different clinically important viruses. Of note, MWPyV-positive samples tested also positive for respiratory syncytial virus types A and B. In this study, we retrieved two complete MWPyV genome sequences from the index samples that were submitted to phylogenetic inference to investigate their viral origin. Our study represents the first molecular and genomic characterization of MWPyV obtained from pediatric patients in South America. The detection of MWPyV in acutely infected infants suggests that this virus might participate (coparticipate) in cases of respiratory symptoms. Nevertheless, future studies based on testing of a larger number of clinical samples and MWPyV complete genomes appear to be necessary to elucidate if this emerging polyomavirus might be clinically important.
Assuntos
COVID-19 , Infecções por Polyomavirus , Polyomavirus , Infecções Respiratórias , Vírus , Lactente , Criança , Humanos , Metagenômica , Brasil/epidemiologia , Malaui/epidemiologia , Filogenia , SARS-CoV-2 , Infecções por Polyomavirus/epidemiologia , Polyomavirus/genética , Infecções Respiratórias/diagnóstico , Infecções Respiratórias/epidemiologiaRESUMO
OBJECTIVES: To assess whether viral, bacterial, metabolic, and autoimmune diseases are missed by conventional diagnostics among children with severe acute encephalopathy in sub-Saharan Africa. STUDY DESIGN: One hundred thirty-four children (6 months to 18 years) presenting with nontraumatic coma or convulsive status epilepticus to 1 of 4 medical referral centers in Uganda, Malawi, and Rwanda were enrolled between 2015 and 2016. Locally available diagnostic tests could be supplemented in 117 patients by viral, bacterial, and 16s quantitative polymerase chain reaction testing, metagenomics, untargeted metabolomics, and autoimmune immunohistochemistry screening. RESULTS: Fourteen (12%) cases of viral encephalopathies, 8 (7%) cases of bacterial central nervous system (CNS) infections, and 4 (4%) cases of inherited metabolic disorders (IMDs) were newly identified by additional diagnostic testing as the most likely cause of encephalopathy. No confirmed cases of autoimmune encephalitis were found. Patients for whom additional diagnostic testing aided causal evaluation (aOR 3.59, 90% CI 1.57-8.36), patients with a viral CNS infection (aOR 7.91, 90% CI 2.49-30.07), and patients with an IMD (aOR 9.10, 90% CI 1.37-110.45) were at increased risk for poor outcome of disease. CONCLUSIONS: Viral and bacterial CNS infections and IMDs are prevalent causes of severe acute encephalopathy in children in Uganda, Malawi, and Rwanda that are missed by conventional diagnostics and are associated with poor outcome of disease. Improved diagnostic capacity may increase diagnostic yield and might improve outcome of disease.
Assuntos
Encefalopatias , Encefalite , Doenças Metabólicas , Criança , Humanos , Encefalopatias/diagnóstico , Encefalopatias/complicações , Encefalite/complicações , Encefalite/diagnóstico , Encefalite/epidemiologia , Estudos de Coortes , MalauiRESUMO
BACKGROUND: In seeking the attainment of Universal Health Coverage (UHC), there has been a renewed emphasis on the role of communities. This article focuses on social innovation and whether this concept holds promise to enhance equity in health services to achieve UHC and serve as a process to enhance community engagement, participation, and agency. METHODS: A cross-country case study methodology was adopted to analyze three social innovations in health in three low- and middle-income countries (LMICs): Philippines, Malawi, and Colombia. Qualitative methods were used in data collection, and a cross-case analysis was conducted with the aid of a simplified version of the conceptual framework on social innovation as proposed by Cajaiba-Santana. This framework proposes four dimensions of social innovation as a process at different levels of action: the actors responsible for the idea, the new idea, the role of the institutional environment, and the resultant changes in the health and social system. RESULTS: The study found that each of the three social innovation case studies was based on developing community capacities to achieve health through community co-learning, leadership, and accountability. The process was dependent on catalytic agents, creating a space for innovation within the institutional context. In so doing, these agents challenged the prevailing power dynamics by providing the communities with respect and the opportunity to participate equally in creating and implementing programs. In this way, communities were empowered; they were not simply participants but became active agents in conceptualizing, implementing, monitoring, and sustaining the social innovation initiatives. CONCLUSION: The study has illustrated how three creative social innovation approaches improved access and quality of health services for vulnerable rural populations and increased agency among the intervention communities. The processes facilitated empowerment, which in turn supported the sustained strengthening of the community system and the achievement of community goals in the domain of health and beyond.
Assuntos
Empoderamento , Cobertura Universal do Seguro de Saúde , Humanos , Malaui , Filipinas , ColômbiaRESUMO
INTRODUCTION: Governments in low-income and middle-income countries (LMICs) and official development assistance agencies use a variety of performance measurement and management approaches to improve the performance of healthcare systems. The effectiveness of such approaches is contingent on the extent to which managers and care providers use performance information. To date, major knowledge gaps exist about the contextual factors that contribute, or not, to performance information use by primary healthcare (PHC) decision-makers in LMICs. This study will address three research questions: (1) How do decision-makers use performance information, and for what purposes? (2) What are the contextual factors that influence the use or non-use of performance information? and (3) What are the proximal outcomes reported by PHC decision-makers from performance information use? METHODS AND ANALYSIS: We present the protocol of a theory-driven, qualitative study with a multiple case study design to be conducted in El Salvador, Lebanon and Malawi.Data sources include semi structured in-depth interviews and document review. Interviews will be conducted with approximately 60 respondents including PHC system decision-makers and providers. We follow an interdisciplinary theoretical framework that draws on health policy and systems research, public administration, organisational science and health service research. Data will be analysed using thematic analysis to explore how respondents use performance information or not, and for what purposes as well as barriers and facilitators of use. ETHICS AND DISSEMINATION: The ethical boards of the participating universities approved the protocol presented here. Study results will be disseminated through peer-reviewed journals and global health conferences.
Assuntos
Atenção à Saúde , Humanos , Líbano , El Salvador , Malaui , Pesquisa QualitativaRESUMO
The development of models that allow improving the quality to achieve person-centered care is a challenge for any health system, especially in low- and middle-income countries, due to the economic difficulties inherent to the countries and to the cost involved in its implementation, which should be assumed by the states, avoiding that the economic burden is assumed by the population, and approaching the goal of universal health coverage. The availability of human talent and efficiency in the use of basic and specialized human talent is a necessity to improve safe access to health services, in this sense, the model proposed by SURG-Africa and whose sustainability in Malawi was evaluated, is an important reference for the establishment and sustainability of these models with other specialties and in other countries. Through this article, the elements of education, care model and financing for the implementation of the strategy in family medicine in the Colombian health system are explored.
Assuntos
Tutoria , Humanos , Malaui , Colômbia , Cobertura Universal do Seguro de Saúde , PolíticasRESUMO
Background: Access to effective mental health services in low- and- middle income countries (LMICs) is limited, leading to a substantial global treatment gap. Amitriptyline, an anti-depressant, and diazepam, an anxiolytic drug, are classified as essential medications by the World Health Organization (WHO). They are the only psychotropic medications whose availability in health facilities is documented as part of Service Provision Assessment surveys. Our objective was to characterize the availability of these medicines in seven countries. Methods: We pooled nationally representative data from Service Provision Assessment surveys of health facilities conducted in Bangladesh, Democratic Republic of Congo (DRC), Haiti, Malawi, Nepal, Senegal, and Tanzania, from 2012 to 2018. We estimated the distribution and determinants of facility-level amitriptyline and diazepam availability in each country. Results: We analysed data from 7958 health facilities. An estimated 8.2% of facilities had amitriptyline and 46.1% had diazepam on the day of assessment. There was significant heterogeneity in both amitriptyline and diazepam availability across countries and within countries across facility characteristics. Multivariable models indicated that hospitals, faith-based and private-for-profit facilities, facilities with more staff, and facilities with more technological resources were more likely to have each medicine, relative to primary care facilities, public sector facilities, facilities with fewer staff, and facilities with fewer technological resources, respectively. Conclusion: Our results indicate limited availability of amitriptyline in health facilities in these seven LMICs. Diazepam is much more commonly available than amitriptyline. Efforts to narrow the global treatment gap for mental health - and especially to integrate mental health services into primary care in LMICs - will be limited without the availability of essential medicines like amitriptyline. Efforts to expand purchasing, distribution, and capacity-building in the appropriate use of essential mental health medicines in LMICs are warranted.