What gaps remain in the HIV cascade of care? Results of a population-based survey in Nsanje District, Malawi

Conan, Nolwenn; Paye, Cyrus; Ortuno, Reinaldo; Chijuwa, Alexander; Chiwandira, Brown; Goemaere, Eric; Garone, Daniela; Coulborn, Rebecca M.; Chihana, Menard; Maman, David

doi:10.1371/journal.pone.0248410

Cited by 8 publications

(14 citation statements)

References 34 publications

(58 reference statements)

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“…Even though a high proportion of FSWs had access to HIV testing, there was a significant number of HIV positive FSWs with HIV viral load of more than 1000 copies/ml. This finding is similar to many studies conducted in Africa 31 , 32 , 33 indicating the need to invest to achieve a population-level viral suppression.…”

Section: Discussionsupporting

confidence: 89%

HIV prevalence and associated factors among female sex workers in Ethiopia, east Africa: A cross-sectional study using a respondent-driven sampling technique

et al. 2022

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Section: Discussionsupporting

confidence: 89%

HIV prevalence and associated factors among female sex workers in Ethiopia, east Africa: A cross-sectional study using a respondent-driven sampling technique

et al. 2022

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“…It is also one of the few HIV studies in Africa to actively recruit adolescent who sell sex into the sample. Encouragingly, PLHIV-FSWs were aware of their HIV status, were on ART, and many were virally suppressed, in some cases surpassing the UNAIDS 90-90-90 targets (our sample was at 95.2%, 98.8%, 83.2%, similar to the general female population of the district) [15]. Yet, these positive notes become more sombre in light of the high prevalence of HIV among some FSWs, with nearly all of those >35 having acquired the disease during their lives (with high STI levels added to risk of contracting and transmitting HIV) [27][28][29].…”

Section: Plos Onementioning

confidence: 68%

“…Women's HIV prevalence among those �15 years has been estimated at 14.0% in Nsanje. Nevertheless, progress has been made towards UNAIDS 90-90-90 indicators: after five years of HIV-focused programming by the Ministry of Health (MoH) and Me ´decins sans Frontières (MSF), 82.4% were said to know their HIV status, 95.7% of PLHIV were on ART, and 90.8% on ART were virally suppressed [15].…”

Section: Introductionmentioning

confidence: 99%

“…Since 2013, MSF has provided HIV, TB, and sexual and reproductive health (SRH) prevention and care services to FSWs in Nsanje using a peer-led, one-stop, sex worker-friendly model [16] following the international recommendations [9]. FSWs are a hard-to-reach and understudied population, and recent district HIV surveys from Nsanje do not provide information on this group despite the fact that their needs are acute and unique, and addressing them will be key to stopping community transmission overall [15]. To date, studies in Malawi have not measured FSWs' awareness of their HIV status using a representative sample.…”

Section: Introductionmentioning

confidence: 99%

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HIV, sexual violence, and termination of pregnancy among adolescent and adult female sex workers in Malawi: A respondent-driven sampling study

et al. 2022

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Female Sex Workers (FSWs) are a hard-to-reach and understudied population, especially those who begin selling sex at a young age. In one of the most economically disadvantaged regions in Malawi, a large population of women is engaged in sex work surrounding predominantly male work sites and transport routes. A cross-sectional study in February and April 2019 in Nsanje district used respondent driven sampling (RDS) to recruit women ≥13 years who had sexual intercourse (with someone other than their main partner) in exchange for money or goods in the last 30 days. A standardized questionnaire was filled in; HIV, syphilis, gonorrhea, and chlamydia tests were performed. CD4 count and viral load (VL) testing occurred for persons living with HIV (PLHIV). Among 363 study participants, one-quarter were adolescents 13–19 years (25.9%; n = 85). HIV prevalence was 52.6% [47.3–57.6] and increased with age: from 14.7% (13–19 years) to 87.9% (≥35 years). HIV status awareness was 95.2% [91.3–97.4], ART coverage was 98.8% [95.3–99.7], and VL suppression 83.2% [77.1–88.0], though adolescent FSWs were less likely to be virally suppressed than adults (62.8% vs. 84.4%). Overall syphilis prevalence was 29.7% [25.3–43.5], gonorrhea 9.5% [6.9–12.9], and chlamydia 12.5% [9.3–16.6]. 72.4% had at least one unwanted pregnancy, 17.9% had at least one abortion (40.1% of which were unsafe). Half of participants reported experiencing sexual violence (SV) (47.6% [42.5–52.7]) and more than one-tenth (14.2%) of all respondents experienced SV perpetrated by a police officer. Our findings show high levels of PLHIV-FSWs engaged in all stages of the HIV cascade of care. The prevalence of HIV, other STIs, unwanted pregnancy, unsafe abortion, and sexual violence remains extremely high. Peer-led approaches contributed to levels of ART coverage and HIV status awareness similar to those found in the general district population, despite the challenges and risks faced by FSWs.

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“…Among Malawian people living with HIV, 90% knew their status, 87% of those who knew their status were on treatment and 92% of those on treatment had achieved viral suppression—rapidly closing the gap in achieving the UNAIDS 95‐95‐95 by 2025 targets [ 1 ]. However, these successes are inconsistent across sub‐populations with groups like men and youth showing disparities in the treatment cascade [ 2 , 3 ]. Innovative strategies are needed to address these disparities; however, effective interventions become more costly as we approach epidemic control [ 4 ].…”

Section: Introductionmentioning

confidence: 99%

Facility‐based HIV self‐testing strategies may substantially and cost‐effectively increase the number of men and youth tested for HIV in Malawi: results from an individual‐based mathematical model

et al. 2022

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Introduction Malawi is rapidly closing the gap in achieving the UNAIDS 95‐95‐95 targets, with 90% of people living with HIV in Malawi aware of their status. As we approach epidemic control, interventions to improve coverage will become more costly. There is, therefore, an urgent need to identify innovative and low‐cost strategies to maintain and increase testing coverage without diverting resources from other HIV services. The objective of this study is to model different combinations of facility‐based HIV testing modalities and determine the most cost‐effective strategy to increase the proportion of men and youth testing for HIV. Methods A data‐driven individual‐based model was parameterized with data from a community‐representative survey (socio‐demographic, health service utilization and HIV testing history) of men and youth in Malawi (data collected August 2019). In total, 79 different strategies for the implementation of HIV self‐testing (HIVST) and provider‐initiated‐testing‐and‐counselling at the outpatient department (OPD) were evaluated. Outcomes included percent of men/youth tested for HIV in a 12‐month period, cost‐effectiveness and human resource requirements. The testing yield was assumed to be constant across the scenarios. Results Facility‐based HIVST offered year‐round resulted in the greatest increase in the proportion of men and youth tested in the OPD (from 45% to 72%–83%), was considered cost‐saving for HIVST kit priced at $1.00, and generally reduced required personnel as compared to the status quo. At higher HIVST kit prices, and more relaxed eligibility criteria, all scenarios that considered year‐round HIVST in the OPD remained on the cost‐effectiveness frontier. Conclusions Facility‐based HIVST is a cost‐effective strategy to increase the proportion of men/youth tested for HIV in Malawi and decreases the human resource requirements for HIV testing in the OPD—providing additional healthcare worker time for other priority healthcare activities.

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What gaps remain in the HIV cascade of care? Results of a population-based survey in Nsanje District, Malawi

Cited by 8 publications

References 34 publications

HIV prevalence and associated factors among female sex workers in Ethiopia, east Africa: A cross-sectional study using a respondent-driven sampling technique

HIV prevalence and associated factors among female sex workers in Ethiopia, east Africa: A cross-sectional study using a respondent-driven sampling technique

HIV, sexual violence, and termination of pregnancy among adolescent and adult female sex workers in Malawi: A respondent-driven sampling study

Facility‐based HIV self‐testing strategies may substantially and cost‐effectively increase the number of men and youth tested for HIV in Malawi: results from an individual‐based mathematical model

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