Inequitable access to neuroimaging represents a critical barrier to paediatric neurological care across sub-Saharan Africa, where fewer than one MRI scanner exists per million people and many children with serious neurological conditions are diagnosed late or not at all. Portable ultra-low-field magnetic resonance imaging (ULF-MRI) offers a potentially transformative pathway to closing this gap, yet evidence supporting its integration into real-world acute paediatric clinical workflows in low-resource hospitals remains scarce. We evaluated the operational feasibility, workflow integration, diagnostic adequacy, and proof-of-concept clinical utility of a portable 64 mT ULF-MRI system at a referral hospital in southern Malawi with no on-site conventional brain imaging.This pilot single-case observational study was conducted at Zomba Central Hospital. A 9-year-old female with progressive neurological decline and suspected white matter disease underwent brain imaging using triplanar T2-weighted and diffusion-weighted protocols on a Hyperfine Swoop 64 mT system. Workflow processes from referral to consensus diagnosis were prospectively documented alongside assessment of image quality, artefacts, diagnostic adequacy, and radiologist diagnostic confidence. Images were uploaded to a cloud platform for remote radiologist review.The complete workflow was accomplished within 22 hours, without sedation or adverse events. All six planned sequences were acquired, yielding whole-brain coverage with diagnostically adequate image quality (overall confidence: 4/5, T2: 4/5; DWI: 3/5). T2-weighted imaging demonstrated bilateral frontal and parietal white matter hyperintensity with a periventricular rim and supratentorial ventricular dilatation; diffusion-weighted imaging and ADC maps showed no restricted diffusion, supporting a chronic process. Integrated with the clinical history, findings supported a working diagnosis of probable juvenile-onset Alexander disease — a leukodystrophy that would otherwise have required referral to a distant facility or remained undiagnosed.These findings demonstrate that portable ULF-MRI, supported by remote radiologist review, can bridge the neuroimaging access gap in low-resource hospitals, enabling timely, radiation-free characterisation of white matter disease for children who would otherwise have no imaging pathway. Larger-scale studies are needed to confirm reproducibility and inform equitable scale-up across similar settings.

Mobile ultra-low-field MRI (ULF-MRI) could reduce inequities in infant neuroimaging in sub-Saharan Africa, but evidence of its feasibility, image quality, and analytic usability remains limited. We evaluated the feasibility, image quality, and analytic usability of mobile 64 mT ULF-MRI for non-sedated infant brain imaging at three and twelve months of age within a longitudinal trial platform in southern Malawi. Feasibility was assessed through visit-level scan uptake and sequence completion; image quality through artifact-based quality control (QC) and radiologist interpretability review; and analytic usability through multi-structure volumetry and correspondence across independent processing workflows.Across 810 eligible visits (3 months: 410; 12 months: 400), 654 MRI sessions were completed (80.7%; 86.6% at 3 months; 74.8% at 12 months), with high sequence acquisition success among completed scans. Of 654 completed sessions, 495 entered artifact-based QC and 442/495 (89.3%) met predefined full-brain quality criteria for volumetric processing; motion-related degradation was the principal determinant of exclusion. Radiologist review (n = 426) rated 396/426 scans (93.0%) as analysable. Volumetry was derived for 215 infants at 3 months and 227 at 12 months, with 99 paired observations demonstrating measurable age-related differences in tissue volumes (grey matter +39.0 ± 7.2%; white matter +48.8± 9.5%). An independent cloud-based pipeline showed high correspondence for supratentorial tissue and total intracranial volume at 12 months (r ≈ 0.97).These findings demonstrate that non-sedated infant ULF-MRI can acheive high uptake, interpretable imaging, and scalable volumetric processing in a low-resource setting. The results support its analytic readiness for integration into developmental neuroscience research where conventional MRI is unavailable.

Population-based studies of common mental health conditions (anxiety, depression, post-traumatic stress disorder) require measures that are valid in the study context. We set out to validate the Generalised Anxiety Disorder-7 scale (GAD-7), Patient Health Questionnaire-9 (PHQ-9); and Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) in the most widely spoken languages in Malawi (Chichewa and Chitumbuka). We undertook translation, adaptation, and piloting to produce final versions in both languages. We conducted criterion validation of the GAD-7, PHQ-9 and PC-PTSD-5 against reference diagnoses of DSM-5 generalised anxiety disorder, major/minor depressive episode, and PTSD respectively, using the Structured Clinical Interview for DSM-5 (SCID-5). A weighted sample of screened participants had SCID interview and this was adjusted for in the analysis. We recruited convenience samples of women and men from two sites: a rural Chitumbuka-speaking site where 342 were screened and 219 had SCID; and an urban Chichewa-speaking site where 458 were screened and 251 had SCID. In both languages, the measures had acceptable internal consistency (Cronbach’s alpha ≥ 0.75). Regarding convergent validity, PHQ-9 and GAD-7 were highly correlated but PC-PTSD-5 was only weakly/moderately correlated with the other measures. In Confirmatory Factor Analysis, best fit for GAD-7 and PC-PTSD-5 was a 1-factor structure, and for PHQ-9 was a 2-factor structure; there was only partial measurement invariance between the 2 language versions of each measure. Area under the ROC curve (AUC) for GAD-7 detection of generalised anxiety disorder was: Chitumbuka 0.759 (95%CI: 0.634, 0.871); Chichewa 0.868 (95%CI: 0.812, 0.915). AUC for PHQ-9 detection of major depression was: Chitumbuka 0.634 (95%CI: 0.441, 0.869); Chichewa 0.843 (95%CI: 0.721, 0.927). AUC for PHQ-9 detection of minor-or-major depression was: Chitumbuka 0.751 (95%CI: 0.619, 0.865); Chichewa 0.801 (95%CI: 0.714, 0.879). AUC for PC-PTSD-5 detection of PTSD was: Chitumbuka 0.682 (95%CI: 0.519, 0.853); Chichewa 0.741 (95%CI: 0.604, 0.859). In conclusion, GAD-7 and PHQ-9 showed good/acceptable validity, although criterion validity of PHQ-9 for major depression in Chitumbuka was poor. PC-PTSD-5 showed limitations to its validity, indicating need for further development of PTSD measures in Malawi.

Anemia and iron-deficiency anemia are prevalent in sub-Saharan Africa (SSA) and linked to impaired brain and developmental outcomes. Progress in understanding these effects is constrained by inconsistent developmental measurement and minimal neuroimaging. This review evaluated how brain growth, cognition, and developmental status have been measured among children under five exposed to anemia, iron deficiency (ID), or iron-deficiency anemia (IDA) in SSA, to assess the availability, reliability, and limitations of neurodevelopmental measurement approaches and implications for comparability and interpretation. A systematic review (PROSPERO CRD42024529208) was conducted following PRISMA guidelines. Six databases were searched for English-language studies published between Jan 1, 2013, and Apr 30, 2024, aligning with the WHO 2013-2025 global nutrition targets. Eligible studies included children aged 0-5 years in SSA exposed to anemia, ID, or IDA and reporting neurodevelopmental outcomes. Findings were synthesized narratively to characterize measurement heterogeneity, reliability reporting, and neuroimaging use. Evidence quality was appraised narratively based on study design and reporting completeness. Of 2254 records screened, 19 studies from nine countries met inclusion criteria. Fourteen studies assessed developmental status, 13 assessed cognition, and only three measured brain outcomes using MRI or near-infrared spectroscopy. Substantial heterogeneity in measurement constructs, assessment tools, cultural adaptations, scoring approaches, and timing of assessment precluded quantitative meta-analysis. Reliability reporting was limited, with psychometric indices reported in seven of 14 developmental studies and nine of 13 cognitive studies. Only three studies incorporated direct measures of brain structure or function, limiting opportunities to relate behavioral outcomes to brain development. Marked measurement heterogeneity, sparse reliability reporting, and the near-absence of neuroimaging constrain epidemiological inference, cross-study comparability, and mechanistic understanding of neurodevelopmental outcomes associated with anemia and ID in SSA. Strengthening culturally grounded assessment frameworks and more equitable, accessible approaches to objective brain measurement are priorities for improving measurement precision and understanding iron-related developmental outcomes.

Introduction:Young rural women are disproportionately affected by negative sexual and reproductive health (SRH) outcomes. However, few sexual health interventions for rural girls document the systematic process of leveraging the cultural tradition and integrating participant input in the development of SRH interventions. Aligning health interventions with familiar cultural practices increases both cultural congruency and relevance. This study aimed to adapt the Yao traditional initiation ceremonies for girls who have attained puberty (Ndakula) and those expecting their first child (Litiwo) into a sexual health intervention for girls who attain puberty in Balaka district in Malawi. Methods:This study employed an Ethnographic Participatory Action Research design, guided by the ADAPT-ITT [Assessment, Decision, Administration, Production, Topical Experts, Integration, Training, and Testing] model. This framework facilitated an iterative process of inquiry and intervention development. We conducted semi-structured in-depth interviews with purposively sampled women from three generations (young women aged 16-24 years, mothers, and grandmothers), traditional and religious SRH counselors, and participant observations of the traditional initiation rites ceremonies (Ndakula and Litiwo). We analyzed data using thematic content analysis. To ensure rigor and trustworthiness of data we employed methodological triangulation, peer debriefing, team analysis, and respondent validation. This comprehensive approach informed the co-creation and testing of a sexual health intervention tailored for rural girls who attain puberty. A descriptive evaluation of the intervention was done after one year of implementation. Results:Findings revealed important community assets including rich indigenous knowledge and a well-structured system for socializing girls and young women on sexuality and expected behaviors across different life stages, deeply rooted in the rituals and traditions of the Yao culture. Older women demonstrated remarkable depth of knowledge, creativity, and commitment in supporting the SRH of young women. At the same time, the study identified critical needs, including misinformation about SRH and women's reproductive physiology that promoted sexual activity during peak fertility periods. These identified assets and needs were collectively leveraged to co-create a culturally grounded SRH intervention for girls who reached menarche which the participants named: Partnership in Action: Health Improvement Intervention (PAHII). After one year of implementation, a descriptive evaluation of PAHII showed a 51.9% reduction in pregnancies and an 82.8% increase in the number of young women using family planning methods. Discussion:Findings support the importance of adapting culturally accepted traditional education, upholding healthy cultural practices, and leveraging deeply rooted values in research and interventions development and implementation. Further research is needed to examine the effectiveness of this sexual health intervention tailored for rural young women on a larger scale.

Sepsis is defined as invasion of pathogens into the blood stream together with the host response to this invasion. Thus, sepsis consists of the systemic inflammatory response syndrome (SIRS)caused by infection. It is a life-threatening condition that requires prompt detection and early definitive medical intervention. Globally, sepsis is common, with an estimated 31.5 million cases per year. Sepsis accounts for a significant in-hospital mortality rate of 17

Background: Heavy alcohol use is common in Malawi among people receiving sexually transmitted infections (STI) care and is a critical barrier to the success of HIV prevention and treatment efforts. Methods: This protocol presents a pilot hybrid type 1 effectiveness-implementation trial evaluating the short-term effectiveness and implementation of a scalable evidence-based intervention (EBI) to reduce alcohol use and provide HIV prevention and treatment counseling for people with heavy drinking receiving STI care in Malawi. We developed a 3-session intervention, Treat4All, that uses motivational interviewing, problem-solving skills, psychoeducation, alcohol refusal, HIV prevention and treatment skills building, and goal setting to reduce alcohol and facilitate engagement in HIV prevention and treatment. We have also integrated HIV prevention content to focus on persistent PrEP use and HIV treatment adherence to improve antiretroviral therapy (ART) adherence and viral suppression. We will conduct a two-arm pilot randomized controlled trial (RCT) in an STI care setting in urban Malawi to compare the preliminary effectiveness and implementation of Treat4All to usual care for decreasing the proportion of heavy drinking days, corroborated with phosphatidylethanol, an alcohol biomarker, and improving HIV outcomes (viral suppression among PWH; PrEP use among those at risk). We will randomly assign 160 people receiving STI care in Lilongwe who report heavy drinking (n = 80 people with HIV; PWH; n = 80 people at high risk of HIV acquisition) to Treat4All or usual care. Discussion: Our study will produce a systematically braided, scalable HIV status-neutral EBI for alcohol reduction and optimization of HIV prevention and treatment behaviors to evaluate in a larger effectiveness-implementation trial. Our study will directly expand alcohol reduction and HIV status-neutral programs for alcohol-impacted populations throughout sub-Saharan Africa and other regions where alcohol contributes to the ongoing HIV epidemic. Clinical trial registration: ClinicalTrials.gov, NCT06668363.

Psychosis in Malawi presents significant challenges for individuals living with psychosis and their caregivers, compounded by stigma, discrimination, and systemic barriers to healthcare access. This study employed a participatory photography method (photovoice) to explore the lived experiences of individuals with psychosis and their caregivers in the Chiradzulu and Salima districts. Sixteen participants, comprising eight People with Lived Experience (PWLE) of psychosis and eight caregivers, documented their experiences and perceptions through photographs. Photovoice participants reported stigma and discrimination in the form of social and economic exclusion and dehumanisation. Love, care, and self-reliance were identified and described as essential to recovery and combating exclusion. In contrast, healthcare access was described as both a facilitator and a challenge to recovery and caregiving. This study underscores the need for targeted community-based and policy-driven interventions to combat stigma and discrimination through intersectoral and multisectoral approaches. It also calls for integrated healthcare services such as task-sharing to address systemic barriers experienced by PWLE of psychosis and improved involvement of individuals with lived experience to improve recovery.

Background Complaints mechanisms are key components of healthcare accountability in health systems across the world. They can help identify structural problems and poor service by individual health workers and can support equitable access and ensure that patient safety is a priority. As part of a larger study on accountability and anti-corruption, the aim of this study was to explore and understand the role of the different channels for complaints that are available to Malawian healthcare users. It aimed to explore how they function, and what undermines their use. Methods We conducted a qualitative study in Blantyre district using participant observations, in-depth interviews and focus group discussions. We spent 8 weeks at health facilities and the Blantyre district health office (Directorate of Health and Social Services) and then explored the challenges of accessing and using patient complaints mechanisms. Results Healthcare users continuously encounter numerous challenges within the Malawian health system. We identified 32 mechanisms for complaints handling and redressal which are also meant to act as tools for checks and balances. At the same time, interviews with health providers, stakeholders and document analysis demonstrated that the complaints and redressal system has multiple weaknesses. These include geographical barriers, lack of trust and visibility of these mechanisms, and limited capacity in institutions to manage the complaints and redress process, as well as lack of political will to adopt changes within the health system. Conclusion The weaknesses of the health complaints and redress system in Malawi pose obstacles to delivering quality primary healthcare to the most disadvantaged communities. Urgent interventions to redesign these mechanisms, ensuring that they are not constrained by power differentials and lack of trust is needed.

Abstract Background The global population is undergoing a significant surge in aging leading to increased susceptibility to various forms of progressive illnesses. This phenomenon significantly impacts both individual health and healthcare systems. Low and Middle Income Countries face particular challenges, as their Primary Health Care (PHC) settings often lack the necessary human and material resources to effectively address the escalating healthcare demands of the older people. This study set out to explore the experiences of older people living with progressive multimorbidity in accessing PHC services in Malawi. Methods Between July 2022 and January 2023, a total of sixty in-depth interviews were conducted with dyads of individuals aged ≥ 50 years and their caregivers, and twelve healthcare workers in three public hospitals across Malawi’s three administrative regions. The study employed a stratified selection of sites, ensuring representation from rural, peri-urban, and urban settings, allowing for a comprehensive comparison of diverse perspectives. Guided by the Andersen-Newman theoretical framework, the study assessed the barriers, facilitators, and need factors influencing PHC service access and utilization by the older people. Results Three themes, consistent across all sites emerged, encompassing barriers, facilitators, and need factors respectively. The themes include: (1) clinic environment: inconvenient clinic setup, reliable PHC services and research on diabetic foods; (2) geographical factors: available means of transportation, bad road conditions, lack of comprehensive PHC services at local health facility and need for community approaches; and (3) social and personal factors: encompassing use of alternative medicine, perceived health care benefit and support with startup capital for small-scale businesses. Conclusion This research highlights the impact of various factors on older people’s access to and use of PHC services. A comprehensive understanding of the barriers, facilitators, and specific needs of older people is essential for developing tailored services that effectively address their unique challenges and preferences. The study underscores the necessity of community-based approaches to improve PHC access for this demographic. Engaging multiple stakeholders is important to tackle the diverse challenges, enhance PHC services at all levels, and facilitate access for older people living with progressive multimorbidity.

Glucocorticoids are understood to represent useful biomarkers of stress and can be measured in saliva, hair, and breastmilk. The collection of such biosamples is increasingly included in biobank and cohort studies. While collection is considered “non-invasive” by biomedical researchers (compared to sampling blood), community perspectives may differ. This cross-sectional, qualitative study utilising eight focus groups aimed to determine the feasibility and acceptability of collecting ostensibly “non-invasive” biological samples in Malawi. Breastfeeding women, couples, field workers, and healthcare providers were purposively sampled. Data about prior understandings of, barriers to, and feasibility of “non-invasive” biosampling were analysed. Participants described biomaterials intended for “non-invasive” collection as sometimes highly sensitive, with sampling procedures raising community concerns. Sampling methods framed as physically “non-invasive” within biomedicine can consequently be considered socially “invasive” by prospective sample donors. Biomedical and community framings of “invasiveness’ can therefore diverge, and the former must respond to and be informed by the perspectives of the latter. Further, considerations of collection procedures are shaped by therapeutic misconceptions about the immediate health-related utility of biomedical and public health research. When researchers engage with communities about biosampling, they must ensure they are not furthering therapeutic misconceptions and actively seek to dispel these.

Ensuring primary healthcare (PHC) accessibility to older people with multimorbidity is vital in preventing unnecessary health deterioration. However, older people ≥50 y of age in low- and middle-income countries (LMICs) face challenges in effectively accessing and utilizing PHC. A systematic review was conducted adopting the Andersen-Newman theoretical framework for health services utilization to assess evidence on factors that affect access to PHC by older people. This framework predicts that a series of factors (predisposing, enabling and need factors) influence the utilization of health services by people in general. Seven publications were identified and a narrative analytical method revealed limited research in this area. Facilitating factors included family support, closeness to the PHC facility, friendly service providers and improved functional status of the older people. Barriers included long distance and disjointed PHC services, fewer health professionals and a lack of person-centred care. The following needs were identified: increasing the number of health professionals, provision of PHC services under one roof and regular screening services. There is a need for more investment in infrastructure development, coordination of service delivery and capacity building of service providers in LMICs to improve access and utilization of PHC services for older people.

Despite collaborative efforts to improve mental health services among youths living with HIV (YLHIVs) aged 15–24, evidence shows that many suffer from depression. We established the correlates of depression and how it affects ART adherence. Structured questionnaires, a Patient Health Questionnaire 9 depression scale assessment, in-depth interviews, and Electronic Medical Record reviews were conducted at the Lighthouse Trust Martin Preus Centre (MPC) ART clinic in Lilongwe from April 2021 to October 2022. A total of 303 YLHIVs aged 15–24 were on ART, and 7 key informants were recruited. Bivariate and multivariate logistic regression analyses were performed using STATA V14.1. A thematic content analysis was used for qualitative data. Forty-six per cent of recruits were male, and fifty-four per cent were female. Seventy-one per cent were aged 20–24, and twenty-nine per cent were aged 15–19. Twenty-three per cent of the YLHIVs had depression symptoms, of whom seventy-nine per cent were aged 20–24 years. Twenty-two per cent had an unsuppressed viral load (non-adherent). Sixty-seven per cent of non-adherent participants were aged 20–24. There was no factor associated with ART non-adherence. Source of income (p = 0.003), alcohol consumption (p = 0.010), and sexual behaviour (p = 0.014) were associated with depression. Sexual behaviour was statistically significantly associated with depression (p = 0.024. The themes were a lack of basic needs, a lack of privacy, psychological trauma, incomplete disclosure, a shortage of psychosocial providers, and a knowledge deficit of ART providers to screen for depression. This study shows that depression is considerably high among YLHIVs in Malawi and linked to ART non-adherence. Strengthening mental health training for providers and routinely screening YLHIVs for depression would help in the early identification and management of depression, thereby improving ART adherence.

A responsive health system must have mechanisms in place that ensure it is accountable to those it serves. Patients in Malawi have to overcome many barriers to obtain care. Many of these barriers reflect weak accountability. There are at least 30 mechanisms through which Malawian patients in the public sector can assert their rights, yet few function well and, as a consequence, they are underused. Our aim was to identify the various channels for complaints and why patients are reluctant to use them when they experience poor quality or inappropriate care, as well as the institutional, social and political factors that give rise to these problems. The study was set in the Blantyre district. We used qualitative methods, including ethnographic observations, focus group discussions, document analysis and interviews with stakeholders involved in complaint handling both in Blantyre and in the capital, Lilongwe. We found that complaints mechanisms and redress procedures are underutilized because of lack of trust, geographical inaccessibility and lack of visibility leading to limited awareness of their existence. Drawing on these results, we propose a series of recommendations for the way forward.

BACKGROUND:Research ethics is intertwined with and depends on building robust and responsive research governance systems alongside researchers. Globally there has been substantial investment in agriculture, nutrition, and health (ANH) research motivated by the need to improve health outcomes, such as micronutrient deficiencies in Sub-Saharan Africa. Although there has been a notable focus on ethical issues inherent in ANH studies, there has been scanty research examining researchers' attitudes related to ANH research. This study was conducted to explore the perspectives of researchers who conducted an agronomic biofortification study in Malawi. METHODOLOGY:In-depth interviews were conducted with a purposive sample of ten ANH researchers. Interviews were conducted online via Zoom, audio-recorded, transcribed verbatim, and thematically analysed using the Leadership, Ethics, Governance and Systems Framework. RESULTS:Four core aspects emerged: Leadership: The relevance of building ethics leadership and ethical competence among researchers. ETHICS:There is a need to develop a framework that operationalises core ethical values that can guide the implementation of ANH research. Governance: Research guidelines were perceived to be too generic to guide ANH research. Systems: Researchers' recommended the establishment of a specialised ANH research ethics committee. CONCLUSIONS:The findings highlight the significance of building ethics leadership and supporting ethical competency amongst researchers. Researchers recommended the development of tailored approaches rather than utilising generic governance systems and frameworks that are drawn from medical research and thus not fit for purpose in this field. In Malawi, specialised ethics review committees are needed to guide ANH research.

This letter explores the societal aspects and healthcare implications that underlie thinking about mpox (formerly known was monkeypox), in the 2022 outbreak, as a sexually transmitted infection (STI). The authors examine what underlies this question, exploring what is an STI, what is sex, and what is the role of stigma in sexual health promotion. The authors argue that, in this specific outbreak, mpox is an STI among men who have sex with men (MSM). The authors highlight the need of critically thinking about how to communicate effectively, the role of homophobia and other inequalities, and the importance of the social sciences.

Maternal mental health (MMH) is recognised as globally significant. The prevalence of depression and factors associated with its onset among perinatal women in Malawi has been previously reported, and the need for further research in this domain is underscored. Yet, there is little published scholarship regarding the acceptability and ethicality of MMH research to women and community representatives. The study reported here sought to address this in Malawi by engaging with communities and healthcare providers in the districts where MMH research was being planned. Qualitative data was collected in Lilongwe and Karonga districts through 20 focus group discussions and 40 in-depth interviews with community representatives and healthcare providers from January through April 2021. All focus groups and interviews were audio recorded, transcribed verbatim (in local languages Chichewa and Tumbuka), translated into English, and examined through thematic content analysis. Participants' accounts suggest that biopsychosocial MMH research could be broadly acceptable within the communities sampled, with acceptability framed in part through prior encounters with biomedical and public health research and care in these regions, alongside broader understandings of the import of MMH. Willingness and consent to participate do not depend on specifically biomedical understandings of MMH, but rather on familiarity with individuals regarded as living with mental ill-health. However, the data further suggest some ‘therapeutic misconceptions’ about MMH research, with implications for how investigations in this area are presented by researchers when recruiting and working with participants. Further studies are needed to explore whether accounts of the acceptability and ethicality of MMH research shift and change during and following research encounters. Such studies will enhance the production of granular recommendations for further augmenting the ethicality of biomedical and public health research and researchers' responsibilities to participants and communities.

Prior research has widely recognized that the most essential negative predictors in people with chronic diseases’ quality of life are insomnia, fatigue, and pain. To date, there are little to no studies that have identified how these physical symptoms perform together and influence the quality of life, especially among people living with Human Immunodeficiency Virus (HIV). This study aimed to examine the relationships between insomnia, fatigue, pain, and quality of life in people with HIV. People living with HIV (N = 200) who met the antiretroviral therapy criteria were recruited. Standardized scales for fatigue, pain, insomnia, antiretroviral therapy adherence, substance use, and quality of life were used to measure key study variables. Results showed with 95% confidence intervals that the increasing levels of fatigue (B = 1.026, p < 0.001) and insomnia (B = –0.589, p = 0.003) were negatively associated with quality of life in people living with HIV. The effect of fatigue on quality of life was significantly mediated via insomnia (Sobel test of mediation effect = 0.225, z = 2.883, p = 0.004). The increasing levels of pain (B = –1.682, p < 0.001) and insomnia (B = –1.171, p < 0.001) were negatively associated with quality of life. The findings of moderated mediation analysis clarified the complex mechanism of how fatigue, insomnia, and opioid use influenced the quality of life and how pain, insomnia, and antiretroviral therapy adherence influence quality of life. It emphasizes the need for further interventions to target this complex interplay among physical symptoms and substance use to enhance the quality of life with antiretroviral therapy in people living with HIV.

Abstract Background: HIV self-testing (HIVST) is an innovative approach that has the potential to improve HIV testing uptake and linkage to care for those who test positive. In this systematic review, we explored barriers and facilitators to HIVST uptake for various populations in Africa. Methodology: We systematically searched multiple electronic databases for relevant English-language articles published between January 2015 and February 2023. The databases included PubMed, Cumulative Index for Nursing and Allied Health Professions Literature (CINAHL), Embase, and Scopus for qualitative research articles on HIVST from different African countries. Findings: A total of 313 articles were identified through a literature search, and 11 met the inclusion criteria. This review shows that HIVST is a highly acceptable method of HIV testing among various populations. Perceived facilitators of the uptake of HIVST were convenience, autonomy and self-empowerment, privacy, confidentiality, and ease of use. The perceived barriers included the cost of self-test kits, perceived unreliability of test results, low literacy, fear and anxiety of a positive test result, potential psychological and social harms, and a lack of linkage to care. Conclusion: This review observes that the establishment of innovative approaches such as mobile phone counselling to support pre- and post-test care for those seeking HIVST is critical for the successful scaling up of this intervention. Furthermore, for resource-poor contexts, affordable HIVST is essential to ensure the absorption of the same.

Malawi has a population of around 20 million people and is one of the world's most economically deprived nations. Severe mental illness (largely comprising psychoses and severe mood disorders) is managed by a very small number of staff in four tertiary facilities, aided by clinical officers and nurses in general hospitals and clinics. Given these constraints, psychosis is largely undetected and untreated, with a median duration of untreated psychosis (DUP) of around six years. Our aim is to work with people with lived experience (PWLE), caregivers, local communities and health leaders to develop acceptable and sustainable psychosis detection and management systems to increase psychosis awareness, reduce DUP, and to improve the health and lives of people with psychosis in Malawi. We will use the UK Medical Research Council guidance for developing and evaluating complex interventions, including qualitative work to explore diverse perspectives around psychosis detection, management, and outcomes, augmented by co-design with PWLE, and underpinned by a Theory of Change. Planned deliverables include a readily usable management blueprint encompassing education and community supports, with an integrated care pathway that includes Primary Health Centre clinics and District Mental Health Teams. PWLE and caregivers will be closely involved throughout to ensure that the interventions are shaped by the communities concerned. The effect of the interventions will be assessed with a quasi-experimental sequential implementation in three regions, in terms of DUP reduction, symptom remission, functional recovery and PWLE / caregiver impact, with quality of life as the primary outcome. As the study team is focused on long-term impact, we recognise the importance of having embedded, robust evaluation of the programme as a whole. We will therefore evaluate implementation processes and outcomes, and cost-effectiveness, to demonstrate the value of this approach to the Ministry of Health, and to encourage longer-term adoption across Malawi.