The MoH requires that ART sites that have adopted the EMR system also continue to run paper-based systems to serve as backup in the eventuality of EMR system failures. EMR data are fi rst backed up on the server at the health facility where the system is running and at an off-site central server on a daily basis. Case registration and information on ART outcomes generated through printouts of master card data in the form of adhesive labels from the EMR are manually transcribed by clinic staff into the paper-based register. The ART supervision team observed that there were differences in the data that were transferred and reported using the paper-based system as compared to the EMR. As national reporting and drug forecasting depends on the EMR, inaccuracies in the paper-based system in case of EMR failure could have important programmatic implications, such as incorrect drug forecasting.Our objective was to assess the extent of inaccuracies in the transcription of case registration and recorded deaths between the EMR and the paper-based data system. METHODS Design, study setting and populationWe conducted a retrospective audit of routine programme data at fi ve ART sites in the central and southern regions of Malawi. These ART sites included three district hospitals (Dedza, Ntcheu and Salima), one mission hospital (St Gabriel's Mission Hospital) and one central hospital (Queen Elizabeth Central Hospital [QECH]). The district hospitals each have two nurses, a clinician and two clerks. They typically attend to more than 200 patients on a clinic day, and their ART registers currently have more than 3000 patients each. QECH has four nurses, three clinical offi cers and two clerks, who attend to more than 400 patients per day; their ART register has more than 10 000 patients. St Gabriel's Mission Hospital has three nurses, two clinicians and one clerk, who see more than 100 patients a day; their ART register includes more than 200 patients. These sites were chosen as they were among the fi rst sites to start ART in Malawi, had high case loads and were among the fi rst to implement the EMR. All these fi ve sites also run paper-based register systems.All patients enrolled in the ART programme up to 31 December 2010 at these fi ve ART sites were included in the study. A review of the paper registers was conducted at all fi ve health facilities between January and February 2011. Interna onal Union Against Tuberculosis and Lung DiseaseHealth solu ons for the poor Setting: Antiretroviral treatment (ART) clinics at one central hospital, three district hospitals and one mission hospital in the central and southern regions of Malawi. Objective: To measure the extent of inaccuracies in the transcription of case registration and recorded deaths between electronic medical data (EMR) and paper registers. This was done to inform the Ministry of Health on the reliability of the paper-based system as backup in case of EMR failure. Design: Retrospective analysis of routine programme data.Results: A total of 31 763 registrations and 2...

IntroductionThe HIV seroprevalence among adult medical inpatients at Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi is approximately 75%, and about one-third of the patients with HIV are on antiretroviral therapy (ART). 1 The proportion of adult medical inpatients on ART increased from 25% in 2013 to 28% in 2014 and 31% in 2015 (Peterson I, QECH electronic patient record data, 2016. Malawi HIV guidelines recommend targeted viral load (VL) testing for patients who have been on ART for at least one year, present with a WHO stage 3 or 4 clinical event, and report good recent adherence to their ART regimen. A switch to a second-line ART regimen is only indicated after a VL result >5000 copies/mL confirms ART failure.2 QECH is a tertiary referral hospital and processes batched dried blood spot (DBS) VL samples in its central laboratory. Inpatients requiring VL testing during admission are instructed to attend the outpatient HIV clinic 3 to 4 weeks later to obtain results. There are already significant challenges in linking HIV-infected patients to regular followup and ART. As the Malawian ART programme continues to develop, there is a greater risk that patients established on ART will present with ART treatment failure and that the current VL testing systems may not be robust enough to meet service demands to facilitate a timely switch of Short Report Challenges with targeted viral load testing for medical inpatients at Queen Elizabeth Central Hospital in Blantyre, MalawiART. We therefore prospectively studied targeted VL testing among adult inpatients at QECH and report outcomes at 8 weeks post-discharge. MethodsEthical approval for this study was granted by the College of Medicine Research and Ethics Committee (COMREC). Over a 4-week period, all adult medical admissions were screened for the following eligibility criteria: patients on ART for at least one year and presenting with a WHO stage 3 or 4 clinical event, with self-reported excellent ART adherence (taken ART as prescribed over the previous one month). Written consent was obtained from each patient. Demographic information, duration on ART, and self-reported ART adherence data were collected through patient interviews and review of clinical files. Inpatient notes were reviewed daily to ascertain whether VL testing was ordered and carried out. At 3, 6, and 8 weeks following patient discharge, the laboratory VL database was checked for available results, which were triangulated with the HIV outpatient clinic electronic database to determine if patients had attended the HIV clinic, received their results, and were switched to second-line treatment (if indicated). Two attempts were made to contact patients via telephone, 8 weeks post-discharge, to obtain information on health status. AbstractBackground Approximately 75% of medical inpatients at Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi are HIV seropositive, and a third of these patients are on antiretroviral therapy (ART). Malawi guidelines recommend targeted viral load (VL) tes...

BackgroundImpressive achievements have been made towards achieving universal coverage of antiretroviral therapy (ART) in sub-Saharan Africa. However, the effects of rapid ART scale-up on delays between HIV diagnosis and treatment initiation have not been well described.MethodsA retrospective cohort study covering eight years of ART initiators (2004–2011) was conducted at Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi. The time between most recent positive HIV test and ART initiation was calculated and temporal trends in delay to initiation were described. Factors associated with time to initiation were investigated using multivariate regression analysis.ResultsFrom 2004–2011, there were 15,949 ART initiations at QECH (56% female; 8% children [0–10 years] and 5% adolescents [10–20 years]). Male initiators were likely to have more advanced HIV infection at initiation than female initiators (70% vs. 64% in WHO stage 3 or 4). Over the eight years studied, there were declines in treatment delay, with 2011 having the shortest delay at 36.5 days. On multivariate analysis CD4 count <50 cells/μl (adjusted geometric mean ratio [aGMR]: aGMR: 0.53, bias-corrected accelerated [BCA] 95% CI: 0.42-0.68) was associated with shorter ART treatment delay. Women (aGMR: 1.12, BCA 95% CI: 1.03-1.22) and patients diagnosed with HIV at another facility outside QECH (aGMR: 1.61, BCA 95% CI: 1.47-1.77) had significantly longer treatment delay.ConclusionsContinued improvements in treatment delays provide evidence that universal access to ART can be achieved using the public health approach adopted by Malawi However, the longer delays for women and patients diagnosed at outlying sites emphasises the need for targeted interventions to support equitable access for these groups.

People living with human immunodeficiency virus (PLHIV) on antiretroviral therapy (ART) are reported to have three times higher carriage ofStreptococcus pneumoniaethan their HIV-uninfected counterparts in point prevalence studies. Using a longitudinal cohort study design, we assessed pneumococcal carriage density, shedding and antibiotic resistance profiles, as well as nasal mucosal immunity, in otherwise healthy PLHIV on ART for at least one year, compared to HIV-uninfected participants in Malawi. Pneumococcal carriage density was higher among PLHIV compared to HIV-uninfected participants. Moreover, PLHIV were twice more likely to shed pneumococci than HIV-uninfected participants. In PLHIV, aerosol shed pneumococci were more often multi-drug resistant (MDR) than nasopharyngeal carried isolates recovered from the same individual. Consistent with high shedding, PLHIV exhibited heightened neutrophil-mediated nasal mucosa inflammation. We propose that PLHIV should be considered in intervention strategies, such as vaccination, as they could be an important reservoir for transmission of MDRS. pneumoniae.

BackgroundSince May 2014, all HIV positive children aged less than five years in Malawi are eligible for ART. For children older than five years they are eligible if they are in WHO stage III/IV, if stage I/II, if their CD4 < 500 cells/mm3. Our goal was to compare the WHO clinical classification criteria (WHO stage + CD4/age) to CD4 count (CD4/age) on all children. Prior to 2014, children aged 2–5 years in stage I and II were eligible for ART if their CD4 was < 750 cells/mm3. We were interested in the increase in numbers of children in this age group who now meet the eligibility criteria and their average CD4 count.MethodsData including age, stage and CD4 count were used. We examined the effect of using two different criteria; WHO staging and checking CD4 count if stage I or II versus CD4 count on all, on the numbers of children eligibility for ART in a cohort of 969 children aged 0 to 14 years in Blantyre, Malawi.ResultsUsing WHO stage + CD4/age, 786 patients out of 969 would have been treated and 183 would not. Using CD4/age, 745 patients out of 969 would have been treated and 224 would not. Within the 224 patients not treated by CD4 classification, 41 were clinical stage III or IV. The most common staging condition in these 41 children was low weight for age (i.e. underweight). 41% of children age2-5 years have a CD4 count >750.ConclusionMost children are correctly started on treatment using recent guidelines. 41% more children <5 years will be started on ART.