How operational research influenced the scale up of antiretroviral therapy in Malawi.
ABSTRACT The national scale up of antiretroviral therapy in Malawi is based on a public health approach, with principles and practices borrowed from the successful World Health Organization "DOTS" tuberculosis control framework. The scale up of antiretroviral therapy was under-pinned by a very strong monitoring and evaluation system, which was used to audit the scale up approach and conduct operational research to answer relevant questions. Examples of research included:- i) access to antiretroviral therapy, populations and social groups served, and how the different groups fared with regard to outcomes; ii) determining whether the quality of data at antiretroviral therapy sites was adequate and whether external supervision was needed; iii) finding feasible ways of reducing the high early mortality in patients starting treatment in both Malawi and the sub-Saharan African region; iv) the causes of loss-to-follow-up, what happened to patients who transferred out of sites and whether transfer-out patients had outcomes comparable to those who did not transfer; and v) the important question of whether antiretroviral therapy scale up reduced population mortality. The answers to these questions had an important influence on how treatment was delivered in the country, and show the value of this work within a programme setting. Key generic lessons include the importance of i) research questions being relevant to programme needs, ii) studies being coordinated, designed and undertaken within a programme, iii) study findings being disseminated at national stakeholder meetings and through publications in peer-reviewed journals and iv) research being used to influence policy and practice, improve programme performance and ultimately patient treatment outcomes.
SourceAvailable from: onlinelibrary.wiley.comTropical Medicine & International Health 09/2013; 18(9):1154-6. DOI:10.1111/tmi.12159 · 2.30 Impact Factor
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ABSTRACT: Despite great efforts to control Tuberculosis (TB), progress is compromised by low adherence to medication, leading to prolonged duration of infectiousness and continued transmission. Investigating low adherence is of high importance from TB programmatic perspective. Though data on actual days of missed treatment exist, the effect of such on TB cure rates has not been investigated. TB operational research data were extracted for smear-positive pulmonary TB patients registered at Zomba Central hospital, Malawi from January 2007 to December 2008. Of the 524 patients, 302 (57.6%) were males and 340 (64.9%) fully adhered to treatment. Excluding 5 individuals with missing data on cure, four hundred and eighty-one (92.7%) were cured of TB, and of these 162 (33.7%) missed at least one day of treatment. Respectively, 49/64 (76.6%) and 71/76 (93.4%) of those who missed treatment in the intensive and continuation phases were cured of TB (p = 0.005). The adjusted logistic regression analysis showed that those who missed 15-29 days of treatment (OR = 0.04, 95% CI: 0.01, 0.14) were less likely to be cured of TB compared with those who fully adhered. Treatment non-adherence was high and was observed even within the first 2 months of treatment. Thus, even at an earlier critical stage of treatment, simple algorithms need to be developed to identify and monitor patients at higher risk of non-adherence. Efforts on treatment compliance counselling should focus on enhanced counselling to improve adherence during the intensive treatment phase.PLoS ONE 05/2013; 8(5):e63050. DOI:10.1371/journal.pone.0063050 · 3.53 Impact Factor
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ABSTRACT: About three-quarters of global deaths from noncommunicable diseases (NCDs) occur in developing countries. Nearly a third of these deaths occur before the age of 60 years. These deaths are projected to increase, fueled by such factors as urbanization, nutrition transition, lifestyle changes, and aging. Despite this burden, there is a paucity of research on NCDs, due to the higher priority given to infectious disease research. Less than 10% of research on cardiovascular diseases comes from developing countries. This paper assesses what lessons from operational research on infectious diseases could be applied to NCDs. The lessons are drawn from the priority setting for research, integration of research into programs and routine service delivery, the use of routine data, rapid-assessment survey methods, modeling, chemoprophylaxis, and the translational process of findings into policy and practice. With the lines between infectious diseases and NCDs becoming blurred, it is justifiable to integrate the programs for the two disease groups wherever possible, eg, screening for diabetes in tuberculosis. Applying these lessons will require increased political will, research capacity, ownership, use of local expertise, and research funding.01/2014; 5:469-82. DOI:10.2147/AMEP.S47412