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: 4.56). 10/2008; 49(3):287-93. DOI: 10.1097/QAI.0b013e3181893ef0
Source: PubMed


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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    • "Malawi, one of the poorest countries in the world, has pioneered the public health approach to ART delivery [3,4]. The public health approach involves decentralisation of ART delivery to primary health care clinics, task-shifting from clinicians to nurses and counsellors, and a reporting system based on collection of facility-level aggregate statistics that allow clear analysis of trends in HIV testing data, uptake of ART and outcomes of ART initiators [5]. "
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    ABSTRACT: Background Impressive achievements have been made towards achieving universal coverage of antiretroviral therapy (ART) in sub-Saharan Africa. However, the effects of rapid ART scale-up on delays between HIV diagnosis and treatment initiation have not been well described. Methods A retrospective cohort study covering eight years of ART initiators (2004–2011) was conducted at Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi. The time between most recent positive HIV test and ART initiation was calculated and temporal trends in delay to initiation were described. Factors associated with time to initiation were investigated using multivariate regression analysis. Results From 2004–2011, there were 15,949 ART initiations at QECH (56% female; 8% children [0–10 years] and 5% adolescents [10–20 years]). Male initiators were likely to have more advanced HIV infection at initiation than female initiators (70% vs. 64% in WHO stage 3 or 4). Over the eight years studied, there were declines in treatment delay, with 2011 having the shortest delay at 36.5 days. On multivariate analysis CD4 count <50 cells/μl (adjusted geometric mean ratio [aGMR]: aGMR: 0.53, bias-corrected accelerated [BCA] 95% CI: 0.42-0.68) was associated with shorter ART treatment delay. Women (aGMR: 1.12, BCA 95% CI: 1.03-1.22) and patients diagnosed with HIV at another facility outside QECH (aGMR: 1.61, BCA 95% CI: 1.47-1.77) had significantly longer treatment delay. Conclusions Continued improvements in treatment delays provide evidence that universal access to ART can be achieved using the public health approach adopted by Malawi However, the longer delays for women and patients diagnosed at outlying sites emphasises the need for targeted interventions to support equitable access for these groups.
    BMC Public Health 05/2013; 13(1):490. DOI:10.1186/1471-2458-13-490 · 2.26 Impact Factor
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    • "While only 13,000 people nationally were receiving treatment in 2004, by the end of 2011, 84% of all health facilities provided ART services, and over 440,000 had initiated ART with more than 320,000 people alive and retained in care [5]. Malawi has accomplished this through an efficient system that has substantial in-country political support matched with consistent external assistance [6–9]. The key features include a gradual increase in the number of sites offering anti-retrovirals; a focus on a single, generic, fixed-dose combination ART; treatment that is delivered free of charge; a standard protocol for starting therapy and for follow-up; and the use of a standard system for registration, monitoring and reporting of cases and outcomes [10]. "
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    ABSTRACT: Introduction The decentralization of HIV services has been shown to improve equity in access to care for the rural poor of sub-Saharan Africa. This study aims to contribute to our understanding of the impact of decentralization on costs borne by patients. Such information is valuable for economic evaluations of anti-retroviral therapy programmes that take a societal perspective. We compared costs reported by patients who received care in an urban centralized programme to those in the same district who received care through rural decentralized care (DC). Methods A cross-sectional survey on patient characteristics and costs associated with accessing HIV care was conducted, in May 2010, on 120 patients in centralized care (CC) at a tertiary referral hospital and 120 patients in DC at five rural health centres in Zomba District, Malawi. Differences in costs borne by each group were compared using χ2 and t-tests, and a regression model was developed to adjust for confounders, using bootstrapping to address skewed cost data. Results There was no significant difference between the groups with respect to sex and age. However, there were significant differences in socio-economic status, with higher educational attainment (p<0.001), personal income (p=0.007) and household income per person (p=0.005) in CC. Travel times were similar (p=0.65), as was time waiting at the clinic (p=0.63) and total time spent seeking care (p=0.65). There was a significant difference in travel-related expenses (p<0.001) related to the type of travel participants noted that they used. In CC, 60% of participants reported using a mini-bus to reach the clinic; in DC only 4% reported using a mini-bus, and the remainder reported travelling on foot or by bicycle. There were no significant differences between the groups in the amount of lost income reported or other out-of-pocket costs. Approximately 91 Malawi Kwacha (95% confidence intervals: 1–182 MKW) or US$0.59 represents the adjusted difference in total costs per visit between CC and DC. Conclusions Even within a system of HIV/AIDS care where patients do not pay to see clinicians or for most medications, they still incur costs. We found that most costs are travel related. This has important implications for poorer patients who live at a distance from health facilities for whom these costs may be significant.
    Journal of the International AIDS Society 03/2013; 16(1):18055. DOI:10.7448/IAS.16.1.18055 · 5.09 Impact Factor
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