To ensure the health of mothers and children, prevention of mother-to-child HIV transmission (PMTCT) programs test women for HIV, engage HIV-positive women in care, and promote recommended breastfeeding practices. Under Malawi’s Option B+ PMTCT program, ~20% of women are lost-to-follow-up (LTFU) and little is known about their breastfeeding practices. The purpose of this study is to describe facilitators and barriers to Option B+ participation and how participation influences breastfeeding duration. We conducted in-depth interviews with HIV-positive women in Option B+ (n = 32) or LTFU from Option B+ (n = 32). They were recruited from four government clinics in Lilongwe District and had a child aged 0–23 months. Women in Option B+ had better disclosure experiences and more social support than LTFU women. The most common reasons for LTFU were fear of HIV disclosure, anticipated or experienced stigma, and insufficient social support. Other reasons included: non-acceptance of HIV status, antiretroviral therapy (ART) side effects, lack of funds for transport, and negative experiences with clinic staff. Worries about possible transmission, even while on ART, influenced timing of weaning for some women in Option B+. Despite their knowledge of the risk of HIV transmission to the child, most LTFU women continued to breastfeed after stopping ART because they considered breastmilk to be an important source of nutrients for the child. Given that HIV-positive Malawian women LTFU from Option B+ breastfeed in the absence of ART, efforts are needed to use evidence-based strategies to address the barriers to Option B+ participation and avert preventable transmission through breastmilk.

Background HIV incidence is higher among pregnant women than their non-pregnant counterparts in some sub-Saharan African settings. Our aims were (1) to estimate HIV incidence during pregnancy and (2) to compare sexual activity between pregnant, postpartum, and non-pregnant women. Methods We examined a retrospective cohort of 1087 women to identify seroconverters using antenatal and labor ward HIV test results. We also conducted a cross-sectional survey, including a quantitative questionnaire (n = 200) and in-depth interviews (n = 20) among women in early pregnancy, late pregnancy, postpartum, and non-pregnancy. Outcomes included measures of sexual activity, reported spouse’s risky behavior, and beliefs about abstinence. Results 11 of 1087 women seroconverted during pregnancy yielding a 1% seroconversion risk and an incidence rate of 4.0/100 person years (95% CI 2.2–7.2). The reported sexual activity of the early pregnancy and non-pregnancy groups was similar, but significantly higher than the late pregnancy and postpartum groups (p<0.001). During pregnancy, sex acts decreased as gestation increased (p = 0.001). There was no reported difference in the spouse’s risky behavior. Most women believed that sex should cease between the 6 th and 8 th month of pregnancy and should not resume until 6 months postpartum. Some talked about conflict between their cultural obligation to abstain and fear of HIV infection if their spouses find other partners. Conclusions HIV incidence is high among pregnant women in Malawi, and sexual activity decreases during pregnancy and postpartum. Pregnant women need to be informed of their increased risk for HIV and the importance of using condoms throughout pregnancy and the postpartum period.

Less than 2% of Malawian women use long-acting reversible contraception (LARC). We describe experiences of Malawian family planning providers, focusing on LARC. We conducted a mixed-methods study using questionnaires and focus group discussions with providers in Lilongwe. Data were analyzed separately and triangulated. Most (58%) participants saw over 30 patients daily. Only 19% had ever inserted IUC. Qualitative data were complementary; participants noted that LARC provision was important, though hindered by lack of experienced providers, work burden, and low demand. Future efforts to improve LARC access in Lilongwe must address both supply and demand-side barriers. (Afr J Reprod Health 2016; 20[2]: 62-71).Keywords: Family planning, long-acting reversible contraception, Malawi. RésuméMoins de 2% des femmes malawiennes utilisent la contraception de longue durée d'action réversible (CLDR). Nous décrivons les expériences des prestataires de planification familiale malawienne, en nous concentrant sur CLDR. Nous avons effectué une étude des méthodes mixtes à l'aide des questionnaires et des discussions de groupes cibles avec les fournisseurs à Lilongwe. Les données ont été analysées séparément et ont été triangulées. La plupart (58%) des participants ont vu plus de 30 patientes par jour. Seulement 19% avaient déjà inséré DIU. Les données qualitatives etaient complémentaires; les participants ont noté que la provision de la CLDR était importante, quoique entravée par le manque de fournisseurs expérimentés, la charge de travail, et la faible demande. Les futurs efforts pour améliorer l'accès à la CLDR à Lilongwe doit s'occuper des deux barrières de coté de l'offre et de la demande. (Afr J Reprod Health 2016; 20[2]: 62-71).Mots-clés: planification familiale, contraception de longue durée d'action réversible, Malawi.

In developing-country settings, pregnancy intentions are often assessed using a series of questions from the Demographic and Health Surveys, yet research conducted in several countries yields conflicting results regarding these questions' ability to predict pregnancy. Conducted in Malawi and South Africa, this study identified individual, partner and societal factors that influence desire for pregnancy, and women's ability to achieve their intentions. Data come from interviews and focus-group discussions conducted prior to the FEM-PrEP HIV-prevention trial with women from communities at high risk of HIV infection. Cultural norms regarding contraceptive use and childbearing influenced both women's desire for pregnancy and ability to achieve those goals. Partner's expectations for pregnancy, financial concerns, family composition and contraceptive experiences were additional influences. Actively planning for pregnancy was not a salient concept to the majority of participants. Results support the call for a multidimensional measure of pregnancy intention that reflects the variety of factors that influence intentions, highlight the fluid nature of many women's reproductive health decision making and challenge the notion that all fertility decisions are the result of conscious action. Additional work on how women's plans for pregnancy are achieved would be programmatically more useful than current measures of intention.

Malawian mothers' and fathers' roles in feeding decision making in the context of HIV align with local gender norms. Strategies are needed to improve fathers' knowledge of and involvement in child feeding, as desired by mothers.

Acute HIV infection (AHI) is a relatively brief period when individuals are highly infectious and the opportunity to intervene to prevent forward transmission is extremely limited. HPTN 062 partnered with CHAVI 001 to evaluate the feasibility and acceptability of a motivational interviewing (MI)-based counseling intervention to reduce HIV-transmission risk behaviors among individuals with acute and early HIV infection in Lilongwe, Malawi. Participants were randomized to receive either (1) brief education sessions about HIV and AHI; or (2) the same brief education sessions plus an MI-based counseling intervention called Uphungu Wanga. Although Uphungu Wanga was determined to be feasible and acceptable, few major differences existed between the two arms with regard to acceptability, feasibility, and self-reported sexual behaviors. We therefore conclude that an additional MI-based counseling intervention may not be needed during the short period of AHI. Instead, we recommend that individuals with AHI receive frequent, but brief, counseling immediately after diagnosis and then transition to receiving counseling at less frequent intervals until they can initiate antiretroviral therapy. Other recommendations are provided.

Before the prevention of mother-to-child transmission (PMTCT) program was widely implemented in Malawi, HIV-positive women associated exclusive breastfeeding with accelerated disease progression and felt that an HIV-positive woman could more successfully breastfeed if she had a larger body size. The relationship between breastfeeding practices and body image perceptions has not been explored in the context of the Option B+ PMTCT program, which offers lifelong antiretroviral therapy. We conducted in-depth interviews with 64 HIV-positive women in Lilongwe District, Malawi to investigate body size perceptions, how perceptions of HIV and body size influence infant feeding practices, and differences in perceptions among women in PMTCT and those lost to follow-up. Women were asked about current, preferred, and healthy body size perceptions using nine body image silhouettes of varying sizes, and vignettes about underweight and overweight HIV-positive characters were used to elicit discussion of breastfeeding practices.More than 80% of women preferred an overweight, obese, or morbidly obese silhouette, and most women (83%) believed that an obese or morbidly obese silhouette was healthy. Although nearly all women believed that an HIV-positive overweight woman could exclusively breastfeed, only about half of women thought that an HIV-positive underweight woman could exclusively breastfeed. These results suggest that perceptions of body size may influence beliefs about a woman's ability to breastfeed. Given the preference for large body sizes and the association between obesity and risk of noncommunicable diseases, we recommend that counseling and health education for HIV-positive Malawian women focus on culturally sensitive healthy weight messaging and its relationship with breastfeeding practices.

This study examined infant and young child feeding (IYCF) counseling, decision-making, and practices among HIV-infected women with children 0–23 months participating in Malawi’s Option B+ prevention of mother-to-child transmission (PMTCT) program. We conducted 160 survey interviews, 32 in-depth interviews, and 32 observations of PMTCT visits. Surveys indicated that exclusive breastfeeding was common (75%) among children < 6 months, while minimum dietary diversity (41%) and minimum acceptable diet (40%) for children 6–23 months occurred less often. In-depth interviews supported these findings. Most women felt comfortable with current breastfeeding recommendations, but chronic food insecurity made it difficult for them to follow complementary feeding guidelines. Women trusted IYCF advice from health workers, but mainly received it during pregnancy. During observations of postnatal PMTCT visits, health workers infrequently advised on breastfeeding (41% of visits) or complementary feeding (29% of visits). This represents a missed opportunity for health workers to support optimal IYCF practices within Option B+.