Improved health outcomes have resulted in people with HIV facing decisions about childbearing. We sought to understand factors associated with desire for a child among men and women in Malawi. HIV-infected men and women ages 18-40 were invited to participate in a brief interview about fertility desires. Single variable logistic regression was used to evaluate factors associated with the outcome of fertility desire. Additionally, multiple logistic regression was used to assess the relationship of all the factors together on the outcome of fertility desire. In-depth interviews with women were performed to understand experiences with reproductive healthcare. A total of 202 brief interviews were completed with 75 men (37.1%) and 127 women (62.9%), with 103 (51.0%) of respondents desiring a child. Being in a relationship (OR 3.48, 95% CI: 1.58 to 7.65, p = 0.002) and duration of HIV more than two years (OR 2.00, 95% CI: 1.08 to 3.67, p=0.03) were associated with increased odds of desire for a child. Age 36-40 years (OR 0.64, 95% CI: 0.46 to 0.90, p = 0.009) and having a living child (OR 0.24, 95% CI: 0.07 to 0.84, p=0.03) were associated with decreased odds of desire for a child. Seventy percent of women (n=19 of 27 respondents) completing semi-structured interviews who responded to the question about decision-making reported that their male partners made decisions about children, while the remainder reported the decision was collaborative (n=8, 30%). Eighty-six percent of women (n=36 of 42 respondents) reported no discussion or a discouraging discussion with a provider about having children. HIV-infected women and men in Malawi maintain a desire to have children. Interventions are needed to integrate safer conception into HIV care, to improve male participation in safer conception counseling, and to empower providers to help patients make decisions about reproduction free of discrimination and coercion.

BackgroundThere is limited understanding of health care providers’ attitudes towards HIV-infected individuals’ reproductive choices, as well as knowledge about safer conception. Our study objective was to explore provider-level factors that serve as barriers and/or facilitators to the provision of reproductive and safer conception services for men and women living with HIV.MethodsTwenty-five providers were interviewed in four focus group discussions about their attitudes regarding childbearing by HIV-infected clients, reproductive health and HIV knowledge, and views and knowledge of safer conception.ResultsProviders reported ambivalence about supporting childbearing among their clients with HIV. They raised concerns about HIV-infected individuals having children, and in certain cases expressed judgment that people with HIV should not have children because of these concerns. Providers lack specific knowledge about safer conception strategies and have low level of knowledge of reproductive health, the efficacy of PMTCT, and the risks of pregnancy for HIV-infected women.ConclusionsProviders in our setting have complex attitudes about HIV-infected clients having children and lack knowledge to appropriately counsel clients about reproductive health and safer conception. Our findings highlight need for further research in this area as well as the need for provider training in reproductive health and safer conception.

Objective To compare one-year outcomes of women started on antiretroviral therapy (ART) during pregnancy in the pre-Option B+ era to those in the Option B+ era. Methods A retrospective chart review was performed at three sites in Malawi. Women were included in the ‘pre-Option B+’ cohort if they started ART during pregnancy for a CD4 count < 350 cells/mm3 or WHO 3/4 condition and in the ‘Option B+’ cohort if they started ART during pregnancy regardless of CD4 count or clinical stage. One-year outcomes were compared using Fisher's exact and ANOVA F-tests. Results A higher proportion of women in the pre-Option B+ cohort started ART at WHO stage 3/4 (11.9% versus 1.1%, P < 0.001), switched ART regimens (5.9% versus 0%, P = 0.002), or died in the first year after starting treatment (3.9% versus .5%, P = 0.05). While more women in the Option B+ cohort had poor adherence or defaulted, these differences were not significant. Conclusions At our study sites, the transition to Option B+ has been associated with ART initiation in women with less advanced HIV infection, improved medication tolerability, and lower mortality. Further research is needed to better understand outcomes of Option B+.

Introduction Rates of abnormal visual inspection with acetic acid (VIA) and prevalence of high-risk human papillomavirus (HPV) subtypes have not been well characterized in HIV-infected women in Malawi. Methods We performed a prospective cohort study of VIA (N=440) in HIV-infected women ages 25-59, with a nested study of HPV subtypes in first 300 women enrolled. Wilcoxon's Rank-Sum Test was used to compare continuous variables and Fisher's exact test was used to compare categorical variables between women with normal versus abnormal VIA. Results: Of 440 women screened, 9.5% (N=42) had abnormal VIA with 69.0% (N=29) having advanced disease not amenable to cryotherapy. Of 294 women with HPV results, 39% (N=114) of women were positive for high-risk HPV infection. Only lower CD4 count (287 cells/mm3 vs. 339 cells/mm3, p=0.03) and high-risk HPV (66.7% versus 35.6%, p<0.01) were associated with abnormal VIA. The most common high-risk HPV subtypes in women with abnormal VIA were 35 (33.3%), 16 (26.7%), and 58 (23.3%). Conclusion Low CD4 cell count was associated with abnormal VIA and raises the importance of early ART and expanded availability of VIA. HPV vaccines targeting additional non-16/18 high-risk HPV subtypes may have greater protective advantages in countries such as Malawi.

Background: The World Health Organization (WHO) recommends screening patients living with AIDS to detect and treat early cryptococcal infection. Methods: The authors evaluated a cryptococcal antigen (CrAg) screening and treatment program at an HIV/AIDS clinic in Malawi. Eligible patients were of age >18 years, had a CD4 count <100 cells/mL or WHO clinical HIV/AIDS stage III or IV. Results: Of 552 patients who presented for care, 113 were eligible, and all (100%) agreed to CrAg screening. Of them, 2 (1.8%; 95% confidence interval [CI]: 0-4.2%) patients were CrAg positive. Among those with CD4 count <100 cells/mL or WHO stage IV, the CrAg prevalence was 3.5% (95% CI: 0-8.4%) and 5.0% (95% CI: 0-15%), respectively. Conclusion: A CrAg screening program was acceptable to new patients in a Malawian HIV/AIDS clinic. The CrAg prevalence for patients with CD4 count < 100 cells/mL and WHO stage IV was consistent with cost-effectiveness estimates. CrAg screening and treatment programs for patients living with AIDS should be expanded.