Mlambe economic and relationship-strengthening intervention for alcohol use decreases violence and improves relationship quality in couples living with HIV in Malawi.

Introduction: A syndemic of unhealthy alcohol use, intimate partner violence (IPV), and economic insecurity threatens to derail progress towards UNAIDS 95-95-95 targets in sub-Saharan Africa. We developed a combined economic and relationship-strengthening intervention called Mlambe to reduce unhealthy alcohol use and increase adherence to antiretroviral therapy for couples in Malawi. This study evaluates the additional impact of Mlambe on IPV and relationship dynamics.

Barriers to accessing care for cardiometabolic disorders in Malawi: partners as a source of resilience for people living with HIV.

Background: People living with HIV (PLWH) are at increased risk of cardiometabolic disorders (CMD). Adequate access to care for both HIV and CMD is crucial to improving health outcomes; however, there is limited research that have examined couples' experiences accessing such care in resource-constrained settings. We aimed to identify barriers to accessing CMD care among PLWH in Malawi and the role of partners in mitigating these barriers.

Pilot Trial Results of Mlambe: An Economic and Relationship-Strengthening Intervention to Address Heavy Drinking and Adherence to Antiretroviral Therapy in Malawi.

We evaluated the feasibility, acceptability, and preliminary efficacy of an economic and relationship-strengthening intervention to reduce heavy alcohol use among couples living with HIV in Malawi (Mlambe). Mlambe consisted of training on financial literacy and relationship skills, combined with 1:1 matched savings accounts to invest in an income-generating activity. In a randomized controlled trial, we compared Mlambe to enhanced usual care (EUC).

"I too have a responsibility for my partner's life": Communal coping among Malawian couples living with HIV and cardiometabolic disorders.

Rationale: HIV and cardiometabolic disorders including hypertension and diabetes pose a serious double threat in Malawi. Supportive couple relationships may be an important resource for managing these conditions. According to the theory of communal coping, couples will more effectively manage illness if they view the illness as "our problem" (shared illness appraisal) and are united in shared behavioral efforts.

"High blood pressure comes from thinking too much": Understandings of illness among couples living with cardiometabolic disorders and HIV in Malawi.

Cardiometabolic disorders (CMD) such as hypertension and diabetes are increasingly prevalent in sub-Saharan Africa, placing people living with HIV at risk for cardiovascular disease and threatening the success of HIV care. Spouses are often the primary caregivers for people living with CMD, and understanding patients' and partners' conceptions of CMD could inform care. We conducted semi-structured interviews with 25 couples having a partner living with HIV and either hypertension or diabetes.

A conceptual framework for understanding child marriage, marriage markets, and marriageability.

The term 'marriageability' is used frequently in child marriage literature but is rarely defined. We propose a conceptual framework to define marriageability and use qualitative case studies to illustrate how ideas about marriageability contribute to child marriage. Pressure to capitalize on a girl's marriageability before it declines in order to secure the 'best' partner may explain why child marriage persists.

"Then I will say that we have to marry each other": A qualitative view of premarital pregnancy as a driver of child marriage in Malawi".

Child marriage is common in Malawi, with 42.1% of women ages 20-24 marrying before age 18. Although global research on child marriage has increased in recent years, the reasons are context-specific and there is limited evidence on specific drivers of child marriage in Malawi.

Community-based empowerment program to delay marriage: Results from the More Than Brides Alliance intervention in India, Malawi, Mali and Niger.

The More Than Brides Alliance (MTBA) implemented an intervention in India, Malawi, Mali and Niger from 2017 to 2020. The holistic community-based program included girls' clubs focused on empowerment and sexual and reproductive health knowledge; work with parents and educators; community edutainment events; and local-, regional-, and national-level advocacy efforts related to child marriage. Using a cluster randomized trial design (India and Malawi), and a matched comparison design (Niger and Mali), we evaluated the effectiveness of the program on age at marriage among girls ages 12-19 in intervention communities.

Development and Validation of the Couple Sexual Satisfaction Scale for HIV and Sexual Health Research.

Sexual satisfaction is an important dimension of relationship quality with implications for sexual and reproductive health (SRH), and HIV prevention, care, and treatment. We developed and validated the Couple Sexual Satisfaction Scale (CSSS) with heterosexual couples in sub-Saharan Africa. Using data from qualitative interviews with 94 partnered women and men in Swaziland and Malawi, we generated a 22-item scale and administered it to 211 couples with at least one partner living with HIV in Malawi.

Perceptions of minimum age at marriage laws and their enforcement: qualitative evidence from Malawi.

Background: Child marriage in Malawi is a significant problem with 42.1% of women 20-24 married by age 18. In 2017 the Malawi government formalized legislation to make marriage under age 18 illegal; violators are subject to fines.

Cohort profile: the mature adults cohort of the Malawi longitudinal study of families and health (MLSFH-MAC).

Purpose: The Mature Adults Cohort of the Malawi Longitudinal Study of Families and Health (MLSFH-MAC) contributes to global ageing studies by providing a rare opportunity to study the processes of individual and population ageing, the public health and social challenges associated with ageing and the coincident shifts in disease burdens, in a low-income, high HIV prevalence, sub-Saharan African (SSA) context.

Participants: The MLSFH-MAC is an open population-based cohort study of mature adults aged 45+ years living in rural communities in three districts in Malawi. Enrolment at baseline is 1266 individuals in 2012.

Bidirectional Violence Is Associated with Poor Engagement in HIV Care and Treatment in Malawian Couples.

Growing evidence suggests that intimate partner violence (IPV) is a barrier to engagement in HIV care. Bidirectional IPV-being both a perpetrator and victim-may be the most common pattern of IPV, yet no research has examined its effect on engagement in care, which could identify couples in most need of interventions. Married couples ( = 211) with at least one partner on antiretroviral therapy were recruited from HIV clinic waiting rooms in Zomba, Malawi.

The Unaddressed Needs of Alcohol-Using Couples on Antiretroviral Therapy in Malawi: Formative Research on Multilevel Interventions.

Alcohol use among HIV-positive individuals in sub-Saharan Africa directly impacts adherence to antiretroviral therapy and HIV outcomes. Few studies have examined approaches to reduce alcohol use among HIV-affected couples, despite evidence that alcohol use is a couple-level concern. We conducted a qualitative study with 23 alcohol-using couples to identify multilevel barriers and facilitators of alcohol use, and potential intervention options with couples.

Evaluating Sampling Biases from Third-party Reporting as a Method for Improving Survey Measures of Sensitive Behaviors.

Survey participants often misreport their sensitive behaviors (e.g., smoking, drinking, having sex) during interviews.

A Dyadic Investigation of Relationship Dynamics and Depressive Symptoms in HIV-Affected Couples in Malawi.

Depression is the leading cause of disability worldwide with health implications for people living with HIV. Primary partnerships like marriage could be protective against depression but may worsen depression depending on the relationship quality. We examined depression and its association with relationship dynamics in a cross-sectional sample of 211 HIV-affected married couples in Malawi.

Marital infidelity, food insecurity, and couple instability: A web of challenges for dyadic coordination around antiretroviral therapy.

Rationale: Despite the importance of primary partners for health, little is known about factors that constrain the ability of couples to work collaboratively towards HIV care and treatment (dyadic coordination). This study examined the interplay of marital infidelity, food insecurity, and couple instability on dyadic coordination and adherence to antiretroviral therapy (ART) in Malawi.

Methods: In 2016, we conducted 80 in-depth interviews with 25 couples with at least one partner on ART.

A new approach to measuring partnership concurrency and its association with HIV risk in couples.

Empirical estimates of the association between concurrent partnerships (CP) and HIV risk are affected by non-sampling errors in survey data on CPs, e.g., because respondents misreport the extent of their CPs.

Cohort Profile: The Malawi Longitudinal Study of Families and Health (MLSFH).

The Malawi Longitudinal Study of Families and Health (MLSFH) is one of very few long-standing, publicly available longitudinal cohort studies in a sub-Saharan African (SSA) context. It provides a rare record of more than a decade of demographic, socioeconomic and health conditions in one of the world's poorest countries. The MLSFH was initially established in 1998 to study social network influences on fertility behaviours and HIV risk perceptions, and over time the focus of the study expanded to include health, sexual behaviours, intergenerational relations and family/household dynamics.

Disability transitions and health expectancies among adults 45 years and older in Malawi: a cohort-based model.

Background: Falling fertility and increasing life expectancy contribute to a growing elderly population in sub-Saharan Africa (SSA); by 2060, persons aged 45 y and older are projected to be 25% of SSA's population, up from 10% in 2010. Aging in SSA is associated with unique challenges because of poverty and inadequate social supports. However, despite its importance for understanding the consequences of population aging, the evidence about the prevalence of disabilities and functional limitations due to poor physical health among older adults in SSA continues to be very limited.

Cohort Profile: The Likoma Network Study (LNS).

The Likoma network study (LNS) investigates the sexual networks connecting the inhabitants of Likoma, a small island of Lake Malawi with high HIV prevalence. Whereas previous studies of sexual networks and HIV/AIDS in sub-Saharan countries have focused solely on the personal networks of a small number of respondents, the LNS attempts to document the sexual networks of the entire adult population of Likoma. To do so, it uses a unique sociocentric study design, in which all members of the local population are contacted for a survey interview and are asked to nominate their five most recent sexual partners.

Should home-based HIV testing and counseling services be offered periodically in programs of ARV treatment as prevention? A case study in Likoma (Malawi).

To reduce HIV incidence, prevention programs centered on the use of antiretrovirals require scaling-up HIV testing and counseling (HTC). Home-based HTC services (HBHTC) increase HTC coverage, but HBHTC has only been evaluated during one-off campaigns. Two years after an initial HBHTC campaign ("round 1"), we conducted another HBHTC campaign ("round 2") in Likoma (Malawi).

Women underestimate the age of their partners during survey interviews: implications for HIV risk associated with age mixing in northern Malawi.

Background: Age mixing may explain differences in HIV prevalence across populations in sub-Saharan countries, but the validity of survey data on age mixing is unknown.

Methods: Age differences between partners are frequently estimated indirectly by asking respondents to report their partner's age. Partner's age can also be assessed directly by tracing partners and asking them to report their own age.

Exploring the relative costs of contact tracing for increasing HIV case finding in sub-Saharan countries.

Background: Contact tracing (CT) has rarely been used to improve HIV case finding in sub-Saharan Africa because of concerns regarding privacy protection and possibly high costs.

Methods: We estimate the relative cost of identifying an undiagnosed HIV infection through CT compared with client-initiated voluntary counseling and testing (VCT) and door-to-door provider-initiated testing (PIT). We used data from the Likoma Network Study, a study of sexual networks and HIV infection conducted on the small island of Likoma in northern Malawi, to inform these calculations.