Ben Morton

Controlled Human Infection Models (CHIM) in which volunteers are experimentally exposed to pathogens are used to study pathogenesis and down select among treatment and vaccine candidates. Scientifically, CHIM studies are best conducted among at-risk populations in which the infection is endemic, and who are likely to benefit from new interventions tested. Ethically, the perspectives of these communities should be carefully considered in designing such research. CHIM studies are often conducted among healthy adults, but we wished to understand study participant’s and community views on conducting CHIM studies in groups other than healthy adults, particularly people living with HIV (PLHIV). We also wished to explore community perceptions of a tuberculosis CHIM (TB CHIM), initially using Bacillus Calmette Guerin (BCG) as a safe intermediate step. We conducted fourteen focus group discussions (FGD) and eight in-depth interviews (IDI) among a wide range of stakeholders including participants, health workers, community advisory groups, religious leaders and medical opinion leaders in Malawi. Discussions and interviews were recorded, transcribed and analysed using thematic and framework analysis. Four themes were described in the data, showing engaged stakeholder acceptance of CHIM studies, and confidence in the research practice and motivation. In the specific examples discussed in this work at-risk populations specifically PLHIV and complex pathogens specifically TB-CHIM, there was concern for safety, proper consent and community consultation. In addition, cultural views on gender roles in Malawi, tissue sampling and residential stays for research study were discussed. Overall, there was support for CHIM among PLHIV, and CHIM working through a BCG CHIM towards safe TB CHIM in future. Appropriate safety caveats and regulatory measures were suggested. Advice on wide, public awareness campaign methods was offered to researchers.

Multimorbidity, the presence of multiple chronic health conditions, is a leading cause of death globally. In Malawi, chronic noncommunicable and communicable diseases such as HIV frequently co-exist, putting pressure on an under-resourced system. However, the health system is primarily structured around disease-specific [vertical] programs, which hinders person-centred care approaches to multimorbidity. Our study focuses on multimorbidity care and explores the perceptions of healthcare workers on the patient pathways and service organisation throughout the patient’s interaction with the health facilities. This cross-sectional qualitative study took an interpretivist approach. We conducted 13 days of clinical observations at Queen Elizabeth Central Hospital and Chiradzulu District Hospital. We also conducted 13 days of clinical observations and semi-structured in-depth interviews with different cadres of purposively sampled healthcare workers (n = 22) at Queen Elizabeth Central Hospital and Chiradzulu District Hospital. Through thematic analysis, we identified an understanding of the organisation of care and healthcare workers’ perspectives on the delivery of services. Findings showed both hospitals provided services for inpatients and outpatients with multimorbidity, including screening, management, prevention of secondary conditions and rehabilitation. Patient diagnosis and management for multimorbidity were often delayed due to frequent stockouts of medication and consumables necessary for diagnostic testing for NCDs at the hospital level. Some healthcare workers were not equipped with the knowledge, skills, or guidelines to manage multimorbidity. As HIV care is currently better resourced than other chronic conditions, healthcare facilities may strengthen the supply chain, healthcare workers’ training sessions and monitoring and evaluation tools to ensure NCDs are well managed, learning from HIV programmes.

Background: Controlled Human Infection Models (CHIM) in which volunteers are experimentally exposed to pathogens are used to study pathogenesis and down select among treatment and vaccine candidates. Scientifically, CHIM studies are best conducted among at-risk populations in which the infection is endemic, and who are likely to benefit from new interventions tested. Ethically, the perspectives of these communities should be carefully considered in designing such research. CHIM studies are often conducted among healthy adults, but we wished to understand study participant’s and community views on conducting CHIM studies in groups other than healthy adults, particularly people living with HIV (PLHIV). We also wished to explore community perceptions of a tuberculosis CHIM (TB CHIM), initially using Bacillus Calmette Guerin (BCG) as a safe intermediate step. Method: We conducted fourteen focus group discussions (FGD) and eight in-depth interviews (IDI) among a wide range of stakeholders including participants, health workers, community advisory groups, religious leaders and medical opinion leaders in Malawi. Discussions and interviews were recorded, transcribed and analysed using thematic and framework analysis . Results: Four themes emerged showing a general acceptance of CHIM studies, and confidence in the research practice and motivation. In the specific examples discussed in this work – at-risk populations specifically PLHIV and complex pathogens specifically TB-CHIM, there was concern for safety, proper consent and community consultation. In addition, cultural views on gender roles in Malawi, tissue sampling and residential stays for research study were discussed. Conclusion: Overall, there was support for CHIM among PLHIV, and CHIM working through a BCG CHIM towards safe TB CHIM in future. Appropriate safety caveats and regulatory measures were suggested. Advice on wide, public awareness campaign methods was offered to advise researchers.

Background: Multimorbidity is an urgent public health threat in sub-Saharan Africa (SSA). However, data on the experiences of people living with multimorbidity (PLWMM) in this context are limited. We explored patient and carer experiences of living with (or caring for) multimorbidity to inform the development of patient-centred interventions for managing multimorbidity. Methods: This qualitative study is nested within a broader programme of multimorbidity research conducted in Malawi and Tanzania across four hospitals. We recruited patients recently discharged from hospital with known two or more combinations of hypertension (HTN), diabetes mellitus (DM), HIV and chronic kidney disease (CKD) and their carers. We conducted primary in-depth interviews at discharge and follow-up interviews 90 days after initial hospital admission to explore longitudinal experiences and care trajectories. FGDs were conducted after hospital discharge. Data were analysed thematically and presented through the lens of an existing Expanded Conceptual Model on Multimorbidity for SSA. Results: We conducted 32 in-depth-interviews (IDI) and 8 focus group discussion (FGDs) with PLWMM and carers in Malawi; and 21 IDIs and 7 FGDs in Tanzania. We identified, and present findings under three key crosscutting themes: experiences of living with multimorbidity; self-management and adaptation; and prioritisation of individual diseases within the multimorbidity paradigm. Age, sex, disease combinations and settings impacted on experiences living with multimorbidity. Out-of-pocket expenditure and poor quality of care dominated both settings with CKD and DM comorbidities exerting the heaviest burden on PLWMM and carers. Treatment discontinuation was common for HTN in Malawi and CKD in Tanzania, whilst living with HTN was linked to emotional distress in both. Older PLWMM reported greater family disruption due to loss of independence. Health crises, health literacy, and financial constraints were major drivers of disease management. Individuals particularly experienced stigma when conditions caused visible signs, and described moral and spiritual concerns. Conclusions: Multimorbidity experiences in Malawi and Tanzania reflect complex interactions between individual, socioeconomic, and health system factors. Effective interventions require multidisciplinary, patient-centred approaches addressing structural barriers, improving health literacy, and promoting collaborative care involving patients, carers, and peers.

The increasing prevalence of multimorbidity in sub-Saharan Africa (SSA) is an urgent concern for health service delivery, yet little is known about how best to support self-management- the tasks patients and carers take to maintain physical and mental health in this context. This review synthesized qualitative evidence that describes self-management of four chronic conditions- HIV, diabetes, chronic kidney disease, and hypertension, including multimorbidity among patients and their carers in SSA. We systematically searched five databases and grey literature for studies published between January 2000 and to March 2025 and conducted a thematic synthesis of findings. Twenty-three studies met inclusion criteria, three of which focused on multimorbidity. Across conditions, patients negotiated self-management based on immediacy of needs and available family support. Patients are motivated to apply biomedical management but are limited by factors such as drug stock-outs and out-of-pocket expenditure. Limited knowledge and low self-efficacy toward self-management of multimorbidity impact decision making and problem solving. We found that diabetes and chronic kidney disease imposed the greatest treatment burden, making them the most challenging conditions for patients to manage. Temporal discontinuation of medications was more prevalent amongst patients with hypertension; and patients with multimorbidity are frequently hypervigilant about their health, more likely to suffer from stress and to seek healthcare. This review synthesised qualitative evidence on self-management of HIV, diabetes, hypertension, and chronic kidney disease in SSA, and considered insights for multimorbidity. Most studies focused on individual conditions, yet our findings reveal strikingly similar challenges across all four conditions: limited health literacy, low self-efficacy, and inadequate structural support. These barriers are likely amplified with multimorbidity, further complicating decision-making and self-management. Addressing these gaps will require context-sensitive interventions that strengthen patient literacy, build confidence to increase patient autonomy and expand the range of resources available to manage chronic disease.

Introduction: Breathlessness is a common cause of hospital admission globally and is associated with high mortality, particularly in low-income countries. In sub-Saharan Africa, there is a paucity of data on breathlessness, with existing data focused on individual diseases. There is a need for patient-centred approaches to understand interactions between multiple conditions to address population needs and inform health system responses. This multicentre prospective study in Malawi aimed to characterise the aetiologies, outcomes and biomarker accuracy for breathless patients. Methods: Adults (aged ≥18 years) admitted to medical wards were consecutively recruited within 24 hours of hospital presentation and followed up for 1 year. Participants with breathlessness (defined as a composite of patient-reported shortness of breath; tachypnoea (respiratory rate ≥25/min); hypoxaemia (SpO ₂ <94%) or treatment with oxygen) were systematically screened against internationally accepted diagnostic criteria. We estimated disease prevalence, survival, health-related quality of life and functional status. We also evaluated diagnostic accuracy of natriuretic peptides for heart failure, and procalcitonin (PCT) and C reactive peptide (CRP) for pneumonia. Results: Of 751 participants, 44% (n=334) had breathlessness, and 316 underwent enhanced diagnostic screening. One-year mortality was higher in breathless patients (51% (157/307)) than those without (26% (100/385)); adjusted HR 1.8 (95% CI 1.4 to 2.3). We identified high prevalence and mortality of heart failure (35% (112/316) prevalence; 69% (75/109) 1-year mortality), anaemia (40% (126/316); 57% (70/122)), pneumonia (41% (131/316); 53% (68/129)) and tuberculosis (29% (91/316); 47% (41/87)). Most participants (63% (199/316)) had multiple conditions. Diagnostic accuracy (area under the curve) for heart failure was 0.89 (brain natriuretic peptide) and 0.88 (N-terminal pro-B-type natriuretic peptide); for pneumonia, CRP was 0.77 and PCT was 0.69. Discussion: Breathlessness-related hospital admissions in Malawi are common, multifactorial and associated with poor survival. This study demonstrates that co-existing conditions are common, highlighting the limitation of single-disease-focused health system responses. Integrated care pathways with context-sensitive diagnostic and treatment approaches are urgently needed to improve survival.

Background: The presence of multiple medical chronic conditions is a growing burden across Africa, where people experience a double burden of communicable and non-communicable diseases (NCD). Integrated chronic disease care at the primary healthcare level is a means to improve person-centred care for people living with multimorbidity. This study aimed to assess public primary healthcare facilities’ service availability and readiness to manage multimorbidity in Malawi, through the lens of HIV, type 2 diabetes, hypertension and chronic kidney disease. We explored healthcare workers’ perceptions of their capacity to provide care for individuals with multimorbidity and the availability of services and resources at their facility. Methods: We conducted a mixed-methods health facility cross-sectional study in primary healthcare facilities in Blantyre and Chiradzulu districts, Malawi. We used the modified WHO Service Availability and Readiness Assessment Tool to assess 12 facilities, and conducted in-depth interviews with 12 purposively selected health facility leads. Availability is presented as the proportion of facilities offering each service. Facility readiness is defined as the mean(percentage) availability of 44 tracer items with a cutoff point of ≥70%, classified as ‘ready’ to manage multimorbidity. Readiness score for individual conditions was also calculated based on the availability of tracer items of that condition with a cutoff point of ≥70%. Results: Of the surveyed facilities, 83%(10/12) offered services for all four selected conditions. Only 30%(3/10) of all facilities had a readiness score of ≥70%, indicative of minimum service delivery requirements for multimorbidity were met. The mean readiness score for type 2 diabetes (65.7%) was the highest, followed by HIV (63.8%), hypertension (60.4%), and chronic kidney disease had the lowest readiness score (22.9%). Barriers to service readiness included nonfunctional diagnostic equipment, frequent drug stockouts and insufficient staffing and supervision, and a lack of clinical guidelines or protocols. Conclusion: The assessed sites were inadequately prepared to provide integrated care for chronic kidney disease, type 2 diabetes, HIV and hypertension. The ability to provide integrated screening and management will require functional diagnostic equipment and consistent drugs. Periodic quality assurance and combined multimorbidity audits could further highlight the gaps in service delivery and give clues to improvement.