Nurses play key roles in educating patients about ART adherence and side effects, but they should also educate patients about CD4 and viral-load test results and about the dangers of using traditional medicines and alcohol with ART. Shorter waiting times at clinics could make ART patients' lives more manageable.

SUMMARY BACKGROUND Data on alcohol abuse as a risk factor for the development of multidrug-resistant tuberculosis (MDR-TB) are scarce. OBJECTIVE To describe the patterns of alcohol use in MDR-TB patients and to determine whether alcohol use is associated with the development of MDR-TB in Botswana. METHODS We compared the level of alcohol use among MDR-TB patients against three control groups: 1) non-MDR-TB patients, 2) human immunodeficiency virus (HIV) infected patients without a history of TB, and 3) the general population. Alcohol use and abuse was measured with the Alcohol Use Disorders Identification Test 10 (AUDIT) questionnaire. RESULTS Of a total national population of 164 MDR-TB cases, 114 (70%) were interviewed. MDR-TB cases had a lifetime prevalence of alcohol use of 35.1%, which was lower than that of all control groups (P < 0.001). MDR-TB cases had higher 1-month prevalence of alcohol dependence symptoms and a lower 1-year period prevalence of alcohol dependence symptoms (P < 0.01 and P = 0.01 respectively). Among patients with TB, alcohol abuse was found to be a risk factor for the development of MDR-TB. CONCLUSION MDR-TB patients in Botswana have high rates of alcohol use and abuse. Among TB patients, alcohol abuse is associated with the diagnosis of MDR-TB, and could be an important modifiable factor.

In Botswana, where one quarter of the adult population is infected with the human immunodeficiency virus and the annual tuberculosis (TB) incidence is among the highest globally, intensified TB case finding is needed in health care facilities to detect and treat TB cases early and prevent transmission. During August-December 2009, TB screening was implemented among adults at patient intake in five clinics in Francistown. Among 11 779 TB screenings at intake, 926 were positive. Nineteen patients were diagnosed with TB. Routine TB screening at intake was operationally feasible, but had low yield. Innovative case-finding strategies are needed in Botswana.

Background: TB remains a major global health problem. It is particularly prevalent in prisons in sub-Saharan Africa due to overcrowding, malnutrition, high HIV prevalence and insufficient medical services. Prisoners have experienced worse TB treatment outcomes than the general population. The researchers investigated the TB treatment outcomes and predictors of unsuccessful treatment outcomesamong prisoners and the general population in Zomba, Malawi. Methods: We retrospectively reviewed TB registers of prisoners and the general population diagnosed with TB from January 2011 to December 2016 at Zomba Maximum Central Prison and Zomba Central Hospital, Malawi. The study used routinely collected data extracted from national, standardized TB treatment monitoring tools. Successful treatment outcome was classified as the total for cured and completed treatment while unsuccessful treatment outcome was classified as the total of deaths and treatment failures. We used descriptive statistics to compare the demographics and TB treatment parameters among prisoners and nonprisoners and computed multivariate analysis to predict the independent factors of unsuccessful treatment outcomes. Results: Of 1652 registered cases, 27% were prisoners (all males) and 72% were non-prisoners (58% males). The median age was 35 years (IQR: 29-42); 76% were Pulmonary TB cases (78% among prisoners vs 75% among general population); 83% were new TB cases (77% among prisoners vs 86% among general population); and 65% were HIV positive (50% among prisoners vs 71% among general population). Regarding treatment outcome, 1472 (89%) were cured and/or completed treatment (93% among prisoners vs 88% among general population), 2(0.2%) were treatment failures, 122 (8%) died (5% among prisoners vs 8% among general population) and 55 (3%) were not evaluated (1% among prisoners vs 4% among general population). Unsuccessful TB treatment outcomes were associated with age greater than 35 years (aOR = 0.68: 95% C.I: 0.58-0.80), Extra-Pulmonary TB (aOR = 1.69: 95% C.I: 1.08-2.63) andHIV positive status (aOR = 0.63: 95% C.I: 0.42-0.94). Conclusion: Maximum prisons provide a stable population that can be easily monitored throughout the course of TB treatment. Good TB treatment outcomes which are comparable to the general population can be achieved among Malawian prisoners despite the challenging prison conditions.

Background Little is known about how to build leadership capacity to support implementation of evidence-based practices within health systems. We observed substantial variability across sites in uptake and sustainability of a peer-led educational outreach intervention for lay health workers (LHWs) providing tuberculosis care in Malawi. Feedback from peer-trainers (PTs) suggested that leadership may have contributed to the variation. We sought to assess the impact of PT leadership style on implementation, and to identify leadership traits of more successful PTs, to inform future implementation planning and to identify targets for leadership capacity building. Methods Qualitative study employing interviews with PTs and LHWs at high and low implementation sites, and review of study team and quarterly PT meeting notes. High implementation sites achieved high uptake, sustainability and fidelity of implementation including: close adherence to training content and process, high levels of coverage (training most or all eligible LHWs at their site), and outcomes were achieved with high levels of self reported competence with the intervention among both PTs and LHWs. Low implementation sites achieved limited coverage (<= 50% of LHWs trained), and intervention fidelity. Results Eight PTs and 10 LHWs from eight high and 10 low implementation sites participated in interviews. Leadership traits of more successful PTs included: flexibility in their approach to training, role modeling and provision of supportive supervision to support learning; addressing challenges proactively and as they occurred; collaborative planning; knowledgeable; and availability to support implementation. Traits unique to less successful PTs included: a poor attitude toward their role as PT and a passive-avoidant approach to challenges. Conclusion This study identified leadership traits more common among unit level leaders at sites with higher uptake, sustainability, and fidelity of implementation. These findings provide a starting point for development and evaluation of a leadership capacity building intervention for unit level leaders to support implementation.

Background Of the 1.8 million adolescents between the ages of 10 and 19 living with HIV globally in 2020; approximately 1.5 million of these live in sub-Saharan Africa. These adolescents living with HIV (ALHIV) are at higher risk of experiencing mental health problems than those without; in Malawi, 18.9% have a depressive disorder. ALHIV can face numerous psychosocial challenges, but little is known about how ALHIV in Malawi perceive these stressors. Understanding psychosocial challenges of ALHIV is a key step in ensuring good mental health care. The aim of this study was to assess the psychosocial challenges faced by ALHIV attending adolescent-specific ART program in Zomba, Malawi. Methods Between April and May 2019, we engaged a purposive sample of ALHIV ages 12–18 (n = 80) in a series of eight focus groups drawing from four Teen Clubs linked to an adolescent-specific ART program. Data were analyzed inductively and deductively to identify themes related to ALHIV psychosocial experiences. Results Two themes that emerged from the study include: 1) stigma and discrimination within communities and families; 2) non-adherence to medications. HIV-related stigma was associated with increased psychological distress; physical and emotional/verbal abuse; low social support, isolation, and a feeling of rejection; and risky health behaviors such as medication hiding and non-adherence to ART. Discriminatory actions were manifested in a form of being given separate utensils for their meals and mistreatment at school. Furthermore, some parents did not allow their children to play with the participants out of fear that HIV transmission. Conclusions Stigma and discrimination are overlooked potential barriers to HIV treatment and care. If HIV services are to effectively meet ALHIVs' needs, mental health interventions are needed to prevent and manage depression and improve adherence to ART. These findings highlight the crucial need to develop culturally relevant mental interventions aimed at helping ALHIV to cope with these diverse challenges.

Anti-retroviral drugs (ARVs) are supplied free of charge in Botswana. Lifelong adherence to antiretroviral therapy (ART) is vital to improve the patient's state of well-being and to prevent the development of strains of the human immunodefi ciency virus (HIV) that are resistant to ART. Persons with ART-resistant strains of HIV can spread these to other people, requiring more expensive ART with more severe side-effects and poorer health outcomes. The purpose of this exploratory, descriptive, qualitative study was to determine nurses' perspectives on Botswana patients' anti-retroviral therapy (ART) adherence, and to identify factors which could promote or hinder ART adherence. Four ART sites were randomly selected and all 16 nurses providing ART services at these sites participated in semi-structured interviews. These nurses indicated that patients' ART adherence was infl uenced by service-related and patient-related factors. Servicerelated factors included the inaccessibility of ART clinics, limited clinic hours, health workers' inability to communicate in patients' local languages, long waiting times at clinics and delays in being informed about their CD4 and viral load results. Nurses could not trace defaulters nor contact them by phone, and also had to work night shifts, disrupting nurse-patient relationships. Patient-related factors included patients' lack of education, inability to understand the signifi cance of CD4 and viral load results, fi nancial hardships, non-disclosure and non-acceptance of their HIV positive status, alcohol abuse, the utilisation of traditional medicines and side effects of ART. The challenges of lifelong ART adherence are multifaceted involving both patient-related and servicerelated factors. Supplying free ARVs does not ensure high levels of ART adherence. OPSOMMINGAnti-retrovirale middels (ARMs) word gratis verskaf in Botswana. Lewenslange getroue nakoming van ARM voorskrifte is noodsaaklik om die pasiënt se algehele staat van welsyn te verbeter en om die ontwikkeling te voorkom van stamme van die menslike immuun-gebrek virus (MIV) wat weerstand bied teen anti-retrovirale behandeling (ARB). Persone met ARB-weerstandbiedende MIV stamme kan dit versprei na ander mense toe, wat duurder ARB vereis met swakker gesondheidsuitkomste. Die doel van hierdie verkennende, beskrywende, kwalitatiewe studie was om te bepaal wat verpleegkundiges se sienings is oor pasiënte in Botswana se nakoming van ARB, en om faktore te identifi seer wat die ARB-nakoming kan bevorder of benadeel. Vier ARB terreine was ewekansig gekies en al 16 verpleegkundiges wat ARB dienste by die terreine verskaf, het deelgeneem aan semi-gestruktureerde onderhoude. Hierdie verleegkundiges het aangedui dat pasiënte se ARB handhawing beïnvloed word deur diens-verwante en pasiënt-verwante faktore. Diens-verwante faktore behels die ontoeganklikheid van ARB klinieke, beperkte kliniekure, gesondheidswerkers se onvermoë om in pasiënte se plaaslike tale te kommunikeer, lang wagtye by klinieke en vertragings om ingelig te wo...

Background: TB remains a major global health problem. It is particularly prevalent in prisons in sub-Saharan Africa due to overcrowding, malnutrition, high HIV prevalence and insufficient medical services. Prisoners have experienced worse TB treatment outcomes than the general population. The researchers investigated the TB treatment outcomes and predictors of unsuccessful treatment outcomes among prisoners and the general population in Zomba, Malawi. Methods: We retrospectively reviewed TB registers of prisoners and the general population diagnosed with TB from January 2011 to December 2016 at Zomba Maximum Central Prison and Zomba Central Hospital, Malawi. The study used routinely collected data extracted from national, standardized TB treatment monitoring tools. Successful treatment outcome was classified as the total for cured and completed treatment while unsuccessful treatment outcome was classified as the total of deaths and treatment failures. We used descriptive statistics to compare the demographics and TB treatment parameters among prisoners and non – prisoners and computed multivariate analysis to predict the independent factors of unsuccessful treatment outcomes.Results : Of 1652 registered cases, 27% were prisoners (all males) and 72% were non-prisoners (58 % males). The median age was 35 years (IQR: 29 - 42); 76 % were Pulmonary TB cases (78 % among prisoners vs 75% among general population); 83 % were new TB cases (77% among prisoners vs 86% among general population); and 65 % were HIV positive (50 % among prisoners vs 71% among general population). Regarding treatment outcome, 1472 (89%) were cured and/or completed treatment (93% among prisoners vs 88 % among general population), 2 (0.2%) were treatment failures, 122 (8%) died (5 % among prisoners vs 8 % among general population) and 55 (3%) were not evaluated (1% among prisoners vs 4% among general population). Unsuccessful TB treatment outcomes were associated with age greater than 35 years (aOR = 0.68: 95% C.I: 0.58 – 0.80), Extra-Pulmonary TB (aOR=1.69: 95% C.I: 1.08 – 2.63) andHIV positive status (aOR = 0.63: 95 % C.I: 0.42 – 0.94).Conclusion: Maximum prisons provide a stable population that can be easily monitored throughout the course of TB treatment. Good TB treatment outcomes which are comparable to the general population can be achieved among Malawian prisoners despite the challenging prison conditions.