Journal Article > ResearchFull Text
BMC Public Health. 2022 February 14; Volume 22 (Issue 1); 295.; DOI: 10.1186/s12889-022-12547-9
Gerstl S, Lee L, Nesbitt RC, Mambula C, Sugianto H, et al.
BMC Public Health. 2022 February 14; Volume 22 (Issue 1); 295.; DOI: 10.1186/s12889-022-12547-9
BACKGROUND
Cervical cancer (CC) is the fourth most common cancer among women worldwide and Malawi has the world's highest rate of cervical cancer related mortality. Since 2016 the National CC Control Strategy has set a screening coverage target at 80% of 25-49-year-old women. The Ministry of Health and Médecins Sans Frontières (MSF) set up a CC program in Blantyre City, as a model for urban areas, and Chiradzulu District, as a model for rural areas. This population-based survey aimed to estimate CC screening coverage and to understand why women were or were not screened.
METHODS
A population-based survey was conducted in 2019. All resident consenting eligible women aged 25-49 years were interviewed (n = 1850) at households selected by two-stage cluster sampling. Screening and treatment coverage and facilitators and barriers to screening were calculated stratified by age, weighted for survey design. Chi square and design-based F tests were used to assess relationship between participant characteristics and screening status.
RESULTS
The percentage of women ever screened for CC was highest in Blantyre at 40.2% (95% CI 35.1-45.5), 38.9% (95% CI 32.8-45.4) in Chiradzulu with supported CC screening services, and lowest in Chiradzulu without supported CC screening services at 25.4% (95% CI 19.9-31.8). Among 623 women screened, 49.9% (95% CI 44.0-55.7) reported that recommendation in the health facility was the main reason they were screened and 98.5% (95% CI 96.3-99.4) recommended CC screening to others. Among 1227 women not screened, main barriers were lack of time (26.0%, 95% CI 21.9-30.6), and lack of motivation (18.3%, 95% CI 14.1-23.3). Overall, 95.6% (95% CI 93.6-97.0) of women reported that they had some knowledge about CC. Knowledge of CC symptoms was low at 34.4% (95% CI 31.0-37.9) and 55.1% (95% CI 51.0-59.1) of participants believed themselves to be at risk of CC.
CONCLUSION
Most of the survey population had heard about CC. Despite this knowledge, fewer than half of eligible women had been screened for CC. Reasons given for not attending screening can be addressed by programs. To significantly reduce mortality due to CC in Malawi requires a comprehensive health strategy that focuses on prevention, screening and treatment.
Cervical cancer (CC) is the fourth most common cancer among women worldwide and Malawi has the world's highest rate of cervical cancer related mortality. Since 2016 the National CC Control Strategy has set a screening coverage target at 80% of 25-49-year-old women. The Ministry of Health and Médecins Sans Frontières (MSF) set up a CC program in Blantyre City, as a model for urban areas, and Chiradzulu District, as a model for rural areas. This population-based survey aimed to estimate CC screening coverage and to understand why women were or were not screened.
METHODS
A population-based survey was conducted in 2019. All resident consenting eligible women aged 25-49 years were interviewed (n = 1850) at households selected by two-stage cluster sampling. Screening and treatment coverage and facilitators and barriers to screening were calculated stratified by age, weighted for survey design. Chi square and design-based F tests were used to assess relationship between participant characteristics and screening status.
RESULTS
The percentage of women ever screened for CC was highest in Blantyre at 40.2% (95% CI 35.1-45.5), 38.9% (95% CI 32.8-45.4) in Chiradzulu with supported CC screening services, and lowest in Chiradzulu without supported CC screening services at 25.4% (95% CI 19.9-31.8). Among 623 women screened, 49.9% (95% CI 44.0-55.7) reported that recommendation in the health facility was the main reason they were screened and 98.5% (95% CI 96.3-99.4) recommended CC screening to others. Among 1227 women not screened, main barriers were lack of time (26.0%, 95% CI 21.9-30.6), and lack of motivation (18.3%, 95% CI 14.1-23.3). Overall, 95.6% (95% CI 93.6-97.0) of women reported that they had some knowledge about CC. Knowledge of CC symptoms was low at 34.4% (95% CI 31.0-37.9) and 55.1% (95% CI 51.0-59.1) of participants believed themselves to be at risk of CC.
CONCLUSION
Most of the survey population had heard about CC. Despite this knowledge, fewer than half of eligible women had been screened for CC. Reasons given for not attending screening can be addressed by programs. To significantly reduce mortality due to CC in Malawi requires a comprehensive health strategy that focuses on prevention, screening and treatment.
Conference Material > Abstract
Lee L, Mbingwani I, Kalua T, Spiers S, Duranti S, et al.
MSF Scientific Days UK 2019: Research. 2019 May 9
INTRODUCTION
Resistance to antiretrovirals (ARV), particularly protease inhibitors (PI), threatens to roll back progress towards expanding access to effective antiretroviral therapy in sub-Saharan Africa. Using routinely collected data from a MSF supported project in rural Malawi, we report ARV resistance and third-line treatment outcomes among patients failing second-line therapy.
METHODS
We analysed data from a retrospective cohort comprising patients failing second-line therapy, involving a PI-containing antiretroviral therapy (ART) regimen, who received genotyping between 2014-2018. Treatment failure was defined as two consecutive high viral loads (VL; >1,000 copies/mL). Third-line was defined as an ART regimen that changed at least two ARVs, and included one integrase inhibitor. Resistance was defined as scores of >=30 using the Stanford University HIV Drug Resistance Database. We used multivariable logistic models to assess the association between PI resistance and key risk factors.
ETHICS
This research fulfilled the exemption criteria set by the MSF Ethics Review Board (ERB) for a posteriori analyses of routinely collected clinical data and thus did not require MSF ERB review. It was conducted with permission from Clair Mills, Operational Centre Paris, MSF.
RESULTS
Among 50,979 patients that were on ART from 2014-2018, 3,579 (7.0%) patients were started on second line. Among 177 patients failing second-line ART that received genotyping, 86 were receiving lopinavir/ritonavir and 91 atazanavir/ritonavir based regimens. Median age was 16.8 years (interquartile range (IQR) 11.8-40.4); 85 (48.0%) were female. Median time on second-line ART was 32.4 months (IQR 15.5-48.6), and 53 patients (29.9%) were resistant to at least one PI. 134 patients (75.7%) were resistant to at least one nucleoside reverse transcriptase inhibitor (NRTI), 29 (16.4%) were resistant to all available NRTIs, and 151 (85.3%) were resistant to at least one non-nucleoside reverse transcriptase inhibitor. PI resistance was more common amongst patients on second-line ART for more than two years (aOR 2.85; 95%CI 1.34-6.06). We did not observe an association between age or gender, and likelihood of PI resistance (age >= 20yr versus <20yr, aOR 1.07, 95%CI 0.55-2.11; male versus female, aOR 1.36, 95%CI 0.69-2.68). For 76 patients (42.9%) switched to third-line ART, retention in care at 12 months after third-line initiation was 97.2% (95%CI 89.4-99.3). VL suppression six and 12 months following third-line initiation was 87.0% (47/54) and 87.9% (29/33), respectively. Amongst 101 patients (57.1%) remaining on second-line ART, retention in care 12 months following genotyping was 89.0% (95%CI 78.9-94.4). VL suppression at six and 12 months following genotyping was 40.0% (24/60) and 45.0% (18/40), respectively.
CONCLUSION
Over 40% of patients failing second-line ART required third-line initiation, highlighting the need for genotyping to identify patients that require third-line therapies and the need for wider access to third-line drugs. We found that patients switched to third-line regimens can achieve good outcomes in a resource-limited setting. Those remaining on second-line treatment experienced poor outcomes, suggesting the need for simpler and better tolerated second-line regimens, and tailored adherence interventions.
CONFLICTS OF INTEREST: None declared.
David Maman started to work for MSF in 2007, and has been medical coordinator in Malawi since February 2018, where MSF France has supported an HIV project since 1996. David is a medical doctor, also holding a Master’s, as well as a PhD, in epidemiology, which he started with Epicentre where he was based for 7 years, both in Paris and in Cape Town. In addition to his MSF work, David is also honorary senior lecturer at the University of Cape Town and co-supervises the PhD’s of two MSF staff.
Resistance to antiretrovirals (ARV), particularly protease inhibitors (PI), threatens to roll back progress towards expanding access to effective antiretroviral therapy in sub-Saharan Africa. Using routinely collected data from a MSF supported project in rural Malawi, we report ARV resistance and third-line treatment outcomes among patients failing second-line therapy.
METHODS
We analysed data from a retrospective cohort comprising patients failing second-line therapy, involving a PI-containing antiretroviral therapy (ART) regimen, who received genotyping between 2014-2018. Treatment failure was defined as two consecutive high viral loads (VL; >1,000 copies/mL). Third-line was defined as an ART regimen that changed at least two ARVs, and included one integrase inhibitor. Resistance was defined as scores of >=30 using the Stanford University HIV Drug Resistance Database. We used multivariable logistic models to assess the association between PI resistance and key risk factors.
ETHICS
This research fulfilled the exemption criteria set by the MSF Ethics Review Board (ERB) for a posteriori analyses of routinely collected clinical data and thus did not require MSF ERB review. It was conducted with permission from Clair Mills, Operational Centre Paris, MSF.
RESULTS
Among 50,979 patients that were on ART from 2014-2018, 3,579 (7.0%) patients were started on second line. Among 177 patients failing second-line ART that received genotyping, 86 were receiving lopinavir/ritonavir and 91 atazanavir/ritonavir based regimens. Median age was 16.8 years (interquartile range (IQR) 11.8-40.4); 85 (48.0%) were female. Median time on second-line ART was 32.4 months (IQR 15.5-48.6), and 53 patients (29.9%) were resistant to at least one PI. 134 patients (75.7%) were resistant to at least one nucleoside reverse transcriptase inhibitor (NRTI), 29 (16.4%) were resistant to all available NRTIs, and 151 (85.3%) were resistant to at least one non-nucleoside reverse transcriptase inhibitor. PI resistance was more common amongst patients on second-line ART for more than two years (aOR 2.85; 95%CI 1.34-6.06). We did not observe an association between age or gender, and likelihood of PI resistance (age >= 20yr versus <20yr, aOR 1.07, 95%CI 0.55-2.11; male versus female, aOR 1.36, 95%CI 0.69-2.68). For 76 patients (42.9%) switched to third-line ART, retention in care at 12 months after third-line initiation was 97.2% (95%CI 89.4-99.3). VL suppression six and 12 months following third-line initiation was 87.0% (47/54) and 87.9% (29/33), respectively. Amongst 101 patients (57.1%) remaining on second-line ART, retention in care 12 months following genotyping was 89.0% (95%CI 78.9-94.4). VL suppression at six and 12 months following genotyping was 40.0% (24/60) and 45.0% (18/40), respectively.
CONCLUSION
Over 40% of patients failing second-line ART required third-line initiation, highlighting the need for genotyping to identify patients that require third-line therapies and the need for wider access to third-line drugs. We found that patients switched to third-line regimens can achieve good outcomes in a resource-limited setting. Those remaining on second-line treatment experienced poor outcomes, suggesting the need for simpler and better tolerated second-line regimens, and tailored adherence interventions.
CONFLICTS OF INTEREST: None declared.
David Maman started to work for MSF in 2007, and has been medical coordinator in Malawi since February 2018, where MSF France has supported an HIV project since 1996. David is a medical doctor, also holding a Master’s, as well as a PhD, in epidemiology, which he started with Epicentre where he was based for 7 years, both in Paris and in Cape Town. In addition to his MSF work, David is also honorary senior lecturer at the University of Cape Town and co-supervises the PhD’s of two MSF staff.
Conference Material > Slide Presentation
Robinson E, Lee L, Roberts L, Poelhekke A, Charles X, et al.
MSF Scientific Days International 2021: Research. 2021 May 18
Conference Material > Abstract
Robinson E, Lee L, Roberts L, Poelhekke A, Charles X, et al.
MSF Scientific Days International 2021: Research. 2021 May 18
INTRODUCTION
The Central African Republic (CAR) has the second-lowest human development index globally and has long been described as being in a state of “silent crisis”. We planned a nationwide study to obtain reliable and comparable mortality data for CAR. Due to the COVID-19 pandemic, only the survey in Ouaka Prefecture proceeded.
METHODS
We conducted a two-stage cluster mortality survey between 9 March and 9 April 2020. We aimed to include 64 clusters of 12 households each, for a target sample size of 3,636 persons. We assigned clusters to communes proportional to population size and used systematic random sampling to identify cluster starting points from a dataset of buildings in each commune. We used a novel approach by: focusing on mortality only; adding an opening question about challenges experienced in the last year to build rapport and document general difficulties; and, for females aged 10-49 years, we included specific pregnancy-related questions to improve detection of neonatal and maternal deaths, and to estimate birth rate. The recall period ran from 26 May 2019 to the interview day (range 289-320 days). We coded reported challenges using a content analysis approach.
ETHICS
This study was approved by the MSF Ethics Review Board (ERB) and the national ERB of CAR.
RESULTS
We reached 50 clusters, including 591 participating households with a total of 4,272 individuals. We identified 160 deaths. Crude and under-five mortality rates (CMR, U5MR) were 1.33 (95% confidence interval, CI, 1.09-1.61) and 1.87 (95%CI 1.37-2.54) deaths/10,000 persons/day, respectively. The most common specified causes of death (COD) for individuals aged >5 years were violence (16.7%; n=20; 95%CI 7.7-32.5) and malaria/fever (9.9%; n=11; 95%CI 5.9-16.2). Amongst children aged <5 years, the most common causes were malaria/fever (30.5%;n=15; 95%CI 17.8-47.1), diarrhoea/vomiting (24.0%; n=11;95%CI 11.9-42.7), neonatal deaths (11.9%; n=6; 95%CI 5.3-24.7), and respiratory infections (6.8%; n=3; 95%CI 2.1-20.1).Amongst females aged 10-49 years, 29.1% (95%CI 26.4-31.9%) were pregnant during the recall period. The birth rate was 59/1,000 population (95%CI 51.7-67.4), and the maternal mortality ratio was 2,525/100,000 live births (95%CI 825-5,794). Reported challenges included concerns about specific illnesses, access to healthcare, bereavement, lack of safe drinking water, insufficient means of subsistence, food insecurity, and violence.
CONCLUSION
Mortality indicators seen here exceed previous estimates, and the CMR is above the humanitarian emergency threshold. New methods used in this study may have improved data completeness and quality. Violence is a leading COD, while other causes highlight poor living conditions and difficulties accessing healthcare and preventive measures; these findings are consistent with reported challenges. The high MMR, despite its lack of precision, alongside the high neonatal death rate and birth rate, call for accessible reproductive healthcare. If our results are generalisable to other regions of CAR, national mortality rates would be among the highest globally. The planned nationwide study should proceed as soon as feasible.
CONFLICTS OF INTEREST
None declared.
The Central African Republic (CAR) has the second-lowest human development index globally and has long been described as being in a state of “silent crisis”. We planned a nationwide study to obtain reliable and comparable mortality data for CAR. Due to the COVID-19 pandemic, only the survey in Ouaka Prefecture proceeded.
METHODS
We conducted a two-stage cluster mortality survey between 9 March and 9 April 2020. We aimed to include 64 clusters of 12 households each, for a target sample size of 3,636 persons. We assigned clusters to communes proportional to population size and used systematic random sampling to identify cluster starting points from a dataset of buildings in each commune. We used a novel approach by: focusing on mortality only; adding an opening question about challenges experienced in the last year to build rapport and document general difficulties; and, for females aged 10-49 years, we included specific pregnancy-related questions to improve detection of neonatal and maternal deaths, and to estimate birth rate. The recall period ran from 26 May 2019 to the interview day (range 289-320 days). We coded reported challenges using a content analysis approach.
ETHICS
This study was approved by the MSF Ethics Review Board (ERB) and the national ERB of CAR.
RESULTS
We reached 50 clusters, including 591 participating households with a total of 4,272 individuals. We identified 160 deaths. Crude and under-five mortality rates (CMR, U5MR) were 1.33 (95% confidence interval, CI, 1.09-1.61) and 1.87 (95%CI 1.37-2.54) deaths/10,000 persons/day, respectively. The most common specified causes of death (COD) for individuals aged >5 years were violence (16.7%; n=20; 95%CI 7.7-32.5) and malaria/fever (9.9%; n=11; 95%CI 5.9-16.2). Amongst children aged <5 years, the most common causes were malaria/fever (30.5%;n=15; 95%CI 17.8-47.1), diarrhoea/vomiting (24.0%; n=11;95%CI 11.9-42.7), neonatal deaths (11.9%; n=6; 95%CI 5.3-24.7), and respiratory infections (6.8%; n=3; 95%CI 2.1-20.1).Amongst females aged 10-49 years, 29.1% (95%CI 26.4-31.9%) were pregnant during the recall period. The birth rate was 59/1,000 population (95%CI 51.7-67.4), and the maternal mortality ratio was 2,525/100,000 live births (95%CI 825-5,794). Reported challenges included concerns about specific illnesses, access to healthcare, bereavement, lack of safe drinking water, insufficient means of subsistence, food insecurity, and violence.
CONCLUSION
Mortality indicators seen here exceed previous estimates, and the CMR is above the humanitarian emergency threshold. New methods used in this study may have improved data completeness and quality. Violence is a leading COD, while other causes highlight poor living conditions and difficulties accessing healthcare and preventive measures; these findings are consistent with reported challenges. The high MMR, despite its lack of precision, alongside the high neonatal death rate and birth rate, call for accessible reproductive healthcare. If our results are generalisable to other regions of CAR, national mortality rates would be among the highest globally. The planned nationwide study should proceed as soon as feasible.
CONFLICTS OF INTEREST
None declared.