A Public Health Approach to Rapid Scale-Up of Antiretroviral Treatment in Malawi During 2004-2006

HIV/AIDS Care and Treatment Branch, Global AIDS Program, US Centers for Disease Control and Prevention, Atlanta, GA, USA.
JAIDS Journal of Acquired Immune Deficiency Syndromes (Impact Factor: 4.39). 10/2008; 49(3):287-93. DOI: 10.1097/QAI.0b013e3181893ef0
Source: PubMed

ABSTRACT Approximately 1 million people are infected with HIV in Malawi, where AIDS is the leading cause of death in adults. By December 31, 2007, more than 141,000 patients were initiated on antiretroviral treatment (ART) by use of a public health approach to scale up HIV services.
We analyzed national quarterly and longitudinal cohort data from October 2004 to December 2006 to examine trends in characteristics of patients initiating ART, end-of-quarter clinical outcomes, and 6- and 12-month survival probability.
During a 27-month period, 72,666 patients were initiated on ART, of whom about two-thirds were women. The percentage of patients initiated on ART who were children and farmers increased from 5.5% to 9.0% and 23% to 32%, respectively (P < 0.001 for trends). Estimated survival probability ranged from 85% to 88% at 6 months and 81% to 84% at 12 months on ART.
In Malawi, a public health approach to ART increased treatment access and maintained high 6- and 12-month survival. Resource-limited countries scaling up ART programs may benefit from this approach of simplified clinical decision making, standardized ART regimens, nonphysician care, limited laboratory support, and centralized monitoring and evaluation.

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Available from: Mindy Hochgesang, Aug 27, 2014
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    • ". National programs [10] [11] [12] [13] have reported large-scale data of HIV treatment in both urban and rural populations [14] [15] [16] [17]; however, delivery of HIV treatment in some settings presents unique challenges and current ART delivery models may significantly limit the accessibility of ART. To have the greatest impact on public health, HIV treatment programs will have to be decentralized and integrated into the existing health care system. "
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    ABSTRACT: Background. Decentralization of antiretroviral therapy (ART) services is a key strategy to achieving universal access to treatment for people living with HIV/AIDS. Our objective was to assess clinical and laboratory outcomes within a decentralized program in Nigeria. Methods. Using a tiered hub-and-spoke model to decentralize services, a tertiary hospital scaled down services to 13 secondary-level hospitals using national and program guidelines. We obtained sociodemographic, clinical, and immunovirologic data on previously antiretroviral drug nave patients aged ≥15 years that received HAART for at least 6 months and compared treatment outcomes between the prime and satellite sites. Results. Out of 7,747 patients, 3729 (48.1%) were enrolled at the satellites while on HAART, prime site patients achieved better immune reconstitution based on CD4+ cell counts at 12 (íµí±ƒ < 0.001) and 24 weeks (íµí±ƒ < 0.001) with similar responses at 48 weeks (íµí±ƒ = 0.11) and higher rates of viral suppression (<400 c/mL) at 12 (íµí±ƒ < 0.001) and 48 weeks (íµí±ƒ = 0.03), but similar responses at 24 weeks (íµí±ƒ = 0.21). Mortality was 2.3% versus 5.0% (íµí±ƒ < 0.001) at prime and satellite sites, while transfer rate was 8.7% versus 5.5% (íµí±ƒ = 0.001) at prime and satellites. Conclusion. ART decentralization is feasible in resource-limited settings, but efforts have to be intensified to maintain good quality of care.
    AIDS research and treatment 06/2014; 2014. DOI:10.1155/2014/560623
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    • "By 2010, over 5 million HIV-infected individuals were receiving antiretroviral therapy (ART) in low and middle income countries (UNAIDS 2010), with rapid scale-up achieved in a number of sub-Saharan African coun- tries_ENREF_2 (Vitoria et al. 2009). In the face of resource and infrastructural constraints, Malawi has demonstrated great success in scaling-up the national ART programmes using a decentralized model and with taskshifting of treatment delivery from physicians to other cadres of health providers (Lowrance et al. 2008). By December 2010, over 300 000 individuals had initiated treatment (Ministry of Health of Malawi 2010). "
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    ABSTRACT: Objective To understand reasons for suboptimal and delayed uptake of antiretroviral therapy (ART) by describing the patterns of HIV testing and counselling (HTC) and outcomes of ART eligibility assessments in primary clinic attendees. Methods All clinic attendances and episodes of HTC were recorded at two clinics in Blantyre. A cohort of newly diagnosed HIV-positive adults (>15 years) was recruited and exit interviews undertaken. Logistic regression models were constructed to investigate factors associated with referral to start ART. Qualitative interviews were conducted with providers and patients. Results There were 2398 episodes of HTC during 18 021 clinic attendances (13.3%) between January and April 2011. The proportion of clinic attendees undergoing HTC was lowest in non-pregnant women (6.3%) and men (8.5%), compared with pregnant women (47.2%). Men had more advanced HIV infection than women (79.7% WHO stage 3 or 4 vs. 56.4%). Problems with WHO staging and access to CD4 counts affected ART eligibility assessments; only 48% completed ART eligibility assessment, and 54% of those reporting WHO stage 3/4 illnesses were not referred to start ART promptly. On multivariate analysis, HIV-positive pregnant women were significantly less likely to be referred directly for ART initiation (adjusted OR: 0.29, 95% CI: 0.13–0.63). Conclusions These data show that provider-initiated testing and counselling (PITC) has not yet been fully implemented at primary care clinics. Suboptimal ART eligibility assessments and referral (reflecting the difficulties of WHO staging in primary care) mean that simplified eligibility assessment tools are required to reduce unnecessary delay and attrition in the pre-ART period. Simplified initiation criteria for pregnant women, as being introduced in Malawi, should improve linkage to ART.
    Tropical Medicine & International Health 02/2012; 17(4):507-17. DOI:10.1111/j.1365-3156.2011.02946.x · 2.30 Impact Factor
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    ABSTRACT: Pain is a leading symptom which influences patients to seek medical attention. The management of pain among patients attending in-patient care in southern African countries has been little described. Information regarding the prevalence of pain and the quality of its management may be useful in guiding clinical decisions, training of health workers and health care quality improvements. A hospital-based audit was conducted to estimate the prevalence of pain and examine the quality of its management among patients admitted to adult medical wards at Queen Elizabeth Central Hospital (QECH), Blantyre, Malawi in 2004. Data were abstracted from ward charts of consecutive patients' who had been either been discharged or had died within a specified period. Characteristics of interest included; socio-demographic data, presence or absence of pain at admission, characterization or description of pain when present, and drug treatment given. Data were analyzed to obtain frequencies and proportions of the characteristics and assess the prevalence of pain and quality of care. A total of 121 patients' case notes were reviewed and the prevalence of pain was recorded for 91 (75.2%) of the patients. Clinicians had recorded pertinent information regarding pain management with the following frequency: pain severity or intensity 5/91 (5.5%), alleviating factors 5 (5.5%), pain radiation 7 (7.7%), exacerbating factors in 9 (9.9%) and periodicity in 43 (47.3%) of the cases. Males with pain were more than 3 times more likely to receive analgesic as compared to females, p < 0.01. Paracetamol was the commonest analgesic prescribed. Inadequate management of pain among patients attending medical wards at QECH was found. There is need for prospective studies to further characterize pain management and identify pain management gaps in Malawi. Interviews of clinicians and documentation of observations within clinical practice are likely to be of value.
    International Archives of Medicine 02/2009; 2(1):6. DOI:10.1186/1755-7682-2-6 · 1.08 Impact Factor
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