Background HIV self-testing increases testing uptake in sub-Saharan Africa but scale-up is challenging because of resource constraints. We evaluated an HIV self-testing intervention integrated into high-burden outpatient departments in Malawi.Methods In this cluster-randomised trial, we recruited participants aged 15 years or older from 15 outpatient departments at high-burden health facilities (including health centres, mission hospitals, and district hospitals) in central and southern Malawi. The trial was clustered at the health facility level. We used constrained randomisation to allocate each cluster (1:1:1) to one of the following groups: standard provider-initiated testing and counselling with no intervention (provider offered during consultations), optimised provider-initiated testing and counselling (with additional provider training and morning HIV testing), and facility-based HIV self-testing (Oraquick HIV self-test, group demonstration and distribution, and private spaces for interpretation and counselling). The primary outcome was the proportion of outpatients tested for HIV on the day of enrolment, measured through exit surveys with a sample of outpatients. Analyses were on an intention-to-treat basis. The trial is registered with ClinicalTrials.gov, NCT03271307, and Pan African Clinical Trials, PACTR201711002697316.

INT J TUBERC LUNG DIS 15(7): 4 HIV is also known to increase the rates of recurrent TB disease after successful completion of treatment for a fi rst episode. [4][5][6] As a result of the impact of HIV, countries with high HIV prevalence have had a two-to fi ve-fold increase in annual TB case notifi cation rates over the last decade. 4,7 This increase in TB burden has adversely affected TB programmes and has strained available human and fi nancial resources at programme level. 4,8 Observational cohort studies in a wide range of settings have demonstrated that antiretroviral treatment (ART), through immune reconstitution, is associated with a 54% to 92% reduction in TB incidence at the individual patient level and a halving of the risk of TB recurrence. 7,9-13 It logically follows that if a large proportion of HIV-positive individuals in high HIV prevalence settings are offered ART, the reduction in TB incidence at the individual patient level should also have a benefi cial impact on TB incidence and case notifi cation at the population level. However, empirical data on the impact of ART on TB case notifi cation at the community level are lacking. 7 Thyolo District in rural southern Malawi had a global and adult HIV prevalence of respectively 10% and 21% in 2007. 14 The district has been progressively scaling up HIV/AIDS (acquired immune-defi ciency syndrome) care and ART since 2003. The district achieved and sustained universal ART access from 2007 onwards (sustained access for at least 80% of those in need). 15,16 We hypothesised that such a large scale-up and coverage of ART at the population level might have been associated with a decrease in district TB case notifi cations. We thus report on trends in new and recurrent TB case notifi cations at the S U M M A R Y

Introduction: There are limited data on factors associated with retention in Option B+. We sought to explore the characteristics of women retained in Option B+ in Malawi, with a focus on the role of HIV disclosure, awareness of partner HIV status, and knowledge around the importance of Option B+ for maternal–child health.Methods: We performed a case-control study of HIV-infected women in Malawi initiated on antiretroviral therapy (ART) under Option B+. Cases were enrolled if they met criteria for default from Option B+ (out of ART for >60 days), and controls were enrolled in approximately 3:1 ratio if they were retained in care for at least 12 months. We surveyed socio-demographic characteristics, HIV disclosure and awareness of partner HIV status, self-report about receiving pre-ART education, and knowledge of Option B+. Univariate logistic regression was performed to determine factors associated with retention. Multivariate logistic regression model was used to evaluate the relationship between HIV disclosure, Option B+ knowledge, and retention after adjusting for age, schooling, and travel time to clinic.Results: We enrolled 50 cases and 153 controls. Median age was 30 years (interquartile range (IQR) 25–34), and the majority (82%) initiated ART during pregnancy at a median gestational age of 24 weeks (IQR 16–28). Ninety-one per cent of the cases (39/43) who started ART during pregnancy defaulted by three months postpartum. HIV disclosure to the primary sex partner was more common among women retained in care (100% versus 78%, p < 0.001). Odds of retention were significantly higher among women with: age >25 years (odds ratio (OR) 2.44), completion of primary school (OR 3.06), awareness of partner HIV status (OR 5.20), pre-ART education (OR 6.17), higher number of correct answers to Option B+ knowledge questions (OR 1.82), and support while taking ART (OR 3.65). Pre-ART education and knowledge were significantly correlated (r = 0.43, p < 0.001). In multivariate analysis, awareness of partner HIV status (OR 4.07, 95% confidence interval (CI) 1.51–10.94, p = 0.02) and Option B+ knowledge (OR 1.60, 95% CI 1.15–2.23, p = 0.004) remained associated with retention.Conclusions: Interventions that address partner disclosure and strengthen pre-ART education around the benefits of ART for maternal and child health should be evaluated to improve retention in Malawi’s Option B+ programme.

Background Little is known about coronavirus disease 2019 (COVID-19) vaccination in Africa. We sought to understand Malawian healthcare workers’ (HCWs’) COVID-19 vaccination and its hypothesized determinants. Methods In March 2021, as the COVID-19 vaccine roll-out commenced in Malawi, we surveyed clinical and lay cadre HCWs (n=400) about their uptake of the vaccine and potential correlates (informed by the WHO Behavioral and Social Drivers of COVID-19 Vaccination framework). We analyzed uptake and used adjusted multivariable logistic regression models to explore how ‘what people think and feel’ constructs were associated with HCWs' motivation to be vaccinated. Results Of the surveyed HCWs, 82.5% had received the first COVID-19 vaccine dose. Motivation (eagerness to be vaccinated) was strongly associated with confidence in vaccine benefits (adjusted OR [aOR] 9.85, 95% CI 5.50 to 17.61) and with vaccine safety (aOR 4.60, 95% CI 2.92 to 7.23), but not with perceived COVID-19 infection risk (aOR 1.38, 95% CI 0.88 to 2.16). Of all the information sources about COVID-19 vaccination, 37.5% were reportedly negative in tone. Conclusions HCWs in Malawi have a high motivation to be vaccinated and a high COVID-19 vaccine uptake. Disseminating vaccine benefits and safety messages via social media and social networks may be persuasive for individuals who are unmotivated to be vaccinated and less likely to accept the COVID-19 vaccine.

Clients with HIV on antiretroviral therapy (ART) perceived the 6-month ART dispensing interval as highly acceptable due to reduced transport costs and increased time for income-generating activities. Providers reported benefits in reduced clinic workload and improved ability to see clients who need more support. Before implementing this dispensing interval on a large scale, countries should conduct further research on how to encourage client health-seeking behaviors for health problems, ensure women have access to family planning services outside of ART clinic visits, and encourage providers to use best practices for counseling messages.