In a rural district hospital setting, at least 9 out of every 10 mothers attending antenatal services accepted VCT, of whom approximately one-quarter were HIV-positive and included in the PMTCT programme. The progressive loss to follow up of more than three-quarters of this cohort by the 6-month postnatal visit demands a 'different way of acting' if PMTCT is to be scaled up in our setting.

CitationCommunity support is associated with better antiretroviral treatment outcomes in a resource-limited rural district in Malawi. This article was originally published in a journal published by Elsevier, and the attached copy is provided by Elsevier for the author's benefit and for the benefit of the author's institution, for non-commercial research and educational use including without limitation use in instruction at your institution, sending it to specific colleagues that you know, and providing a copy to your institution's administrator. Summary A study was carried in a rural district in Malawi among HIV-positive individuals placed on antiretroviral treatment (ART) in order to verify if community support influences ART outcomes. Standardized ART outcomes in areas of the district with and without community support were compared. Between April 2003 (when ART was started) and December 2004 a total of 1634 individuals had been placed on ART. Eight hundred and ninety-five (55%) individuals were offered community support, while 739 received no such support. For all patients placed on ART with and without community support, those who were alive and continuing ART were 96 and 76%, respectively (P < 0.001); death was 3.5 and 15.5% (P < 0.001); loss to follow-up was 0.1 and 5.2% (P < 0.001); and stopped ART was 0.8 and 3.3% (P < 0.001). The relative risks (with 95% CI) for alive and on ART [1.26 (1.21-1.32)], death [0.22 (0.15-0.33)], loss to followup [0.02 (0-0.12)] and stopped ART [0.23 (0.08-0.54)] were all significantly better in those offered community support (P < 0.001). Community support is associated with a considerably lower death rate and better overall ART outcomes. The community might be an unrecognized and largely 'unexploited resource' that could play an important contributory role in countries desperately trying to scale up ART with limited resources. All other uses, reproduction and distribution, including without

Summary This paper describes (a) the experience of initiating community involvement in HIV/AIDS and tuberculosis (TB) activities in a rural district in Malawi and (b) some of the different ways in which the community is contributing in the fight against these two diseases and the outcomes of their involvement. During a 2-year period, a total of 21 358 (41%) of 52 510 HIV tests performed at voluntary counselling and HIV testing (VCT) sites in the district were conducted by lay community counsellors. A team of 465 community volunteers, 1362 trained family caregivers and 9 community nurses provided care and support to 5106 HIV-positive individuals, of whom 2006 (39%) were in WHO stage III or IV. All those in WHO stage III or IV were on co-trimoxazole prophylaxis and 895 (45%) of these were also on antiretroviral treatment. A total of 2714 TB patients, of whom 1627 (60%) were HIV-positive, also received care and support. A total of 1694 orphans were trained in vocational skills. Twelve vegetable gardens and three maize farms were set up, and pre-school activities were organised for 900 orphans. Communities can play an important contributory role in reducing the burden of HIV/AIDS and TB and in mitigating its impact. Despite this, community resources in most settings are often under-exploited and their role remains undefined.

Objectives: To describe health seeking and sexual behaviour including condom use among patients presenting with sexually transmitted infections (STIs) and, to identify sociodemographic and behavioural risk factors associated with "no condom use" during the symptomatic period. Methods: A cross sectional study of consecutive new STI cases presenting at the district STI clinic in Thyolo, Malawi. They were interviewed by STI counsellors after obtaining informed consent. All patients were treated according to national guidelines. Results: Out of 498 new STI clients, 53% had taken some form of medication before coming to the STI clinic, the most frequent alternative source being the traditional healer (37%). 46% of all clients reported sex during the symptomatic period (median 14 days), the majority (74%) not using condoms. 90% of all those who had not used condoms resided in villages and had seen only the traditional healer. Significant risk factors associated with "no condom use" included visiting a traditional healer, being female, having less than 8 years of school education, and being resident in villages. Genital ulcer disease (GUD) was the most common STI in males (49%) while in females this comprised 27% of STIs. Conclusions: These findings, and especially the extremely high GUD prevalence is of particular concern, considering the high national HIV prevalence in Malawi (9%) and the implications for STI and HIV transmission. There is an urgent need to integrate traditional healers in control activities, encourage their role in promoting safer sexual behaviour, and to reorient or even change existing strategies on condom promotion and STI control. S exually transmitted infections (STIs) are known to facilitate the sexual transmission of HIV 1 2 and effective STI case management is known to reduce the incidence of HIV.3 Malawi has both high HIV and high STI rates. The national HIV prevalence in Malawi is 9%, while among antenatal women the syphilis seroprevalence is estimated at 2-10%. 4 In 1990, 42% of antenatal clinic attendees were diagnosed with at least one STI and HIV infection rates among patients with STIs range from 53-83%.5 STI control in Malawi is therefore of major public health importance.An important determinant of effective STI control is the health seeking behaviour of people with STIs who may seek care from alternative sources (outside an official STI clinic) such as traditional healers, private clinics, pharmacists, and market vendors.Traditional healers in particular are well reputed in African rural communities and are often considered to be the most appropriate initial point of contact for help when symptoms of STIs are thought to be linked to traditional beliefs and related perceptions. 6 Knowledge about the relative importance of these alternative providers in STI control could encourage better collaboration with some of these groups, encourage early referral for effective antibiotic treatment, and help remove or reduce potential barriers to STI control.Control of STIs involves not only pro...

A study was conducted among individuals seeking voluntary HIV counselling and testing (VCT) in order to (a) describe their motives and source(s) of information, (b) describe their sexual behaviour; and (c) identify risk factors associated with HIV infection. Of 723 individuals who sought VCT, the most common reason (50%) was recent knowledge of HIV/AIDS and a desire to know their HIV status. The majority (77%) underwent VCT after being encouraged by others who knew their status. Ninety five per cent reported sexual encounters, with 337 (49%) engaging in unprotected sex. HIV prevalence was 31% and an HIV-positive status was associated with being female, being over 25 years of age and/or being a farmer. There is a demand for VCT, and the service provides an opportunity for intensive education about HIV/AIDS prevention on a one-to-one basis. It could also be an entry point to prevention and care for those who are infected.