High levels of adherence to antiretroviral therapy (ART) are essential to promoting viral suppression and consequential good treatment outcomes. Adolescents living with HIV (ALHIV) in sub-Saharan Africa are less adherent to ART compared to adults, leading to lower rates of viral suppression and immunological recovery. We conducted a mixed-method study utilizing a convergent parallel approach to explore factors associated with ART adherence among ALHIV in the era of isoniazid preventive therapy (IPT) as part of HIV care. The quantitative data were collected from patient records from the period between 1 February 2017 and 31 January 2018 (6 months before and after IPT introduction), while qualitative data was collected from purposively selected patients and healthcare workers by in-depth interviews through a pretested interview guide. A total of 385 patient records (age 10–19 years) were analyzed in the two time periods, while 16 ALHIV (age 10–19 years) and three healthcare workers directly involved in adolescent care were interviewed. Quantitative data utilized logistic regression to measure the strength of association between IPT addition and ART adherence, whereas, qualitative data were analyzed using a thematic analysis approach. The mean age of participants in the quantitative section was 14.3 years (SD 2.7) and 178 were females, while the median age for adolescents interviewed was 14 (IQR 12–17) and 8 were females. Overall, we found an interaction of factors that influenced ART adherence. Added pill burden, on its own, did not affect ART adherence. Commonly reported factors that led to poor adherence were lack of status disclosure within the family, school pressure, and inadequate support from guardians and parents. According to retrospective patient records, complex ART regimens also worsened adherence (p = 0.0462). ART regimen was independently associated with adherence (OR 2.11 95% CI 0.97–4.53). Being on ART for a longer duration, enrolment into teen clubs, clinical psychosocial support, and self-reinforcement techniques were suggested to improve ART adherence. The interplay of multiple factors leads to poor rates of adherence. The introduction of IPT to ART packages may not independently affect ART adherence. Readily available psychosocial services and the presence of peer and guardian support is critical to optimal ART adherence. There is a need for ART centers that provide HIV care to adolescents to consider integrating psychosocial and other youth-friendly services into day-to-day clinic operations.

The majority of African children with cancer die without access to resources. We describe efforts to build a public treatment program with curative intent for childhood cancer in Lilongwe, Malawi despite severe limitations in diagnostic and therapeutic resources. We retrospectively analyzed a cohort of childhood cancer patients at Kamuzu Central Hospital from 12/2011–6/2013. Consistently available chemotherapeutic agents were limited to cyclophosphamide, vincristine, doxorubicin, bleomycin, methotrexate, and prednisone. Of 258 newly diagnosed childhood malignancies, 17 patients with retinoblastoma were excluded from clinical analyses due to insufficient clinical data. Among the remainder of the cohort (n = 241), 42% were female with median age 8.4 years (range 0.6–17.9). Forty-six (19%) were HIV-infected (42 Kaposi sarcoma, 3 Burkitt lymphoma, 1 Hodgkin lymphoma). The most common clinical presentations were palpable abdominal mass (41%), peripheral lymphadenopathy (33%), and jaw mass (17%). Nearly two-thirds of total diagnoses were accounted for by Burkitt lymphoma (n = 74), Kaposi sarcoma (n = 52), Hodgkin lymphoma (n = 21), and Wilms tumor (n = 19). Twelve-month overall survival for these 4 most common diagnoses was 54% (95% confidence interval 46–61) versus 19% (95% confidence interval 11–30) for all other diagnoses (median follow-up 19 months). Treatment-related mortality was highest in patients with non-Wilms solid tumors of the abdomen (48% versus 10% for the overall cohort, p < 0.001), while treatment abandonment was highest in patients with bone and soft-tissue sarcomas (29% versus 14% overall, p = 0.05). Childhood cancers with excellent curative potential accounted for the majority of patients, establishing an opportunity to build treatment programs with curative intent despite severe limitations.

Background Globally, countries are working tirelessly to achieve the UNAIDS 95-95-95 treatment targets by 2030. Despite making great strides in improving HIV viral load (VL) testing capacity for treatment monitoring in the past decade, a limited number of people living with HIV ( PLHIV) with high VL complete intensive adherence counselling (IAC) sessions which delays follow-up VL testing, consequently, delaying clinical decision-making. This study explored factors associated with the completion of IAC sessions in resource-limited settings.Methods We conducted a mixed-method study utilizing the explanatory sequential design. The quantitative data were collected from patient records from the period between 1 March 2020 to 30 June 2021 in Neno district, while qualitative data were collected from purposively selected PLHIV with high VL and healthcare workers, through focus group discussions (FGDs) and in-depth interviews respectively. 371 patient records were analyzed, while 6 heterogeneous FGDs of patients with high VL were conducted. 15 healthcare workers were also interviewed. STATA software was used to analyze quantitative data while thematic analysis approach was used for qualitative data analysis.Results The median age of the participants at the most recent VL was 39 years (IQR 31–47 years). The median age of respondents in FGDs was 41 years ( IQR 20–57). We found that having community health worker support (ARR = 0.62; 95% CI = 0.39–0.99) and longer duration on ART (ARR = 1.76; 95% CI = 1.09–2.83) were significant predictors of IAC completion. Provider’s unprofessionalism, poor partner support, and lack of private rooms for conducting IAC sessions dissuaded clients to come for subsequent IAC sessions.Conclusion Clients with high VL encounter multiple challenges that affect IAC attendance. Although personal factors play a greater role in fulfilling IAC attendance, health system factors are equally important. ART Clinics need to devise deliberate and careful approaches that target and motivate at-risk clients to complete IAC sessions and improve overall adherence. There’s an urgent need for ART clinics to designate private rooms for IAC sessions and adequately train expert clients on professionalism.

PURPOSE: Few data describe the modern epidemiology of pediatric HIV-associated cancers in sub-Saharan Africa, home to over 80% of the world's children living with HIV. This study evaluated the incidence of cancers among these children over 15 years after widespread antiretroviral therapy (ART) adoption in Malawi. METHODS: We conducted a retrospective population-based cohort study leveraging multiple independent data sources comprehensive of all cancer diagnoses among children living with HIV in Northern and Central Malawi between 2010 and 2024. HIV-associated cancers were defined as those cancers with well-established epidemiologic associations with HIV. Cumulative incidence and average annual percent change were estimated using joinpoint regression. Next, we conducted a subcohort analysis within the country's largest pediatric HIV clinic to evaluate cancer risk factors using log-binomial regression. RESULTS: Among 1,686 pediatric cancer diagnoses, 184 (10.9%) occurred in children with HIV. Kaposi sarcoma (KS) accounted for 96% of cases. The cumulative incidence of HIV-associated malignancies fell from 4.7 cases per million children in 2010 to 1.2 per million in 2024, representing an 84% decline from its peak in 2013 and an average annual percent decline of 13% ( P < .001). KS dropped from the third- to seventh-most common childhood cancer in the region. Notably, 58% of affected children were ART-naïve at diagnosis. Initiating ART in infancy reduced the risk of KS by 69% ( P < .001). Other HIV-associated cancers were rare, comprising 0.4% of all cases diagnosed. CONCLUSION: National ART expansion substantially reduced pediatric HIV-associated cancers in Malawi, achieving declines comparable with those seen in high-income countries. Sustained early diagnosis and ART linkage remain essential to sustain progress.

Background: Monitoring peripartum women’s engagement in Option B+ is essential for preventing vertical HIV transmission but remains suboptimal. Quality improvement (QI) may strengthen monitoring, but its use in Option B+ is underexplored. This study assessed implementation fidelity of Process Mapping and Quality Improvement (PROMAQI), a blended QI strategy, and examined monitoring and six-month retention. Methods: This implementation fidelity study was conducted in five high-volume facilities in Lilongwe, Malawi, from August 2021 to March 2022, with a nested pre-post uncontrolled quasi-experimental component. PROMAQI included QI capacity-building, mentorship, peer learning, communication, documentation, and resource support. Fidelity was assessed from QI records using content, frequency, duration, and coverage domains and classified as high (≥ 80%), moderate (50–79%), or low (< 50%). Pre- and post-intervention cohorts were identified from routine records. HIV clinic attendance and missed visits were assessed over six months from first antenatal care visit, summarized for months 1–3 and 4–6 of follow-up, and compared descriptively and using logistic regression adjusted for site and visit. Six-month retention was summarized descriptively. Results: Overall fidelity was moderate (62.7%), with high content adherence (81.0%) and moderate frequency (50.0%), duration (50.0%), and coverage (69.7%). Among 692 women (pre: 392; post: 300; median age: 28 years), HIV clinic attendance declined over follow-up in both periods, while missed visits increased less after PROMAQI implementation. Adjusted analyses showed reduced odds of missed visits during months 4–6 of follow-up (OR 0.28; 95% CI 0.17–0.47) and higher odds of HIV clinic attendance (OR range: 2.13–3.47). The proportion with at least one documented HIV clinic visit increased from 64.0% to 72.0% in months 1–3 ( p = 0.022) and from 31.0% to 63.0% in months 4–6 ( p < 0.001). Among women already on ART, ≥ 2 visits increased from 28.0% to 56.0% ( p < 0.001); among newly initiated women, ≥ 4 visits increased from 33.0% to 42.0% ( p = 0.120). Six-month retention increased from 44.0% to 72.0%, while missing outcome data declined from 41.0% to 3.7%. Conclusion: PROMAQI achieved moderate fidelity, with strong capacity-building but gaps in communication and activity intensity. Implementation was associated with improved monitoring and higher recorded six-month retention. Findings highlight opportunities to strengthen PROMAQI components in high-volume Option B+ settings.