[Show abstract][Hide abstract] ABSTRACT: Early access to tuberculosis diagnosis and treatment remains a challenge in developing countries. General use of informal providers such as storekeepers is common. The aim of this study was to determine the effectiveness and acceptability of a storekeeper-based referral system for TB suspects in urban settings of Lilongwe, Malawi.
The referral system intervention was implemented in two sub-districts. This was evaluated using a pre and post comparison as well as comparison with a third sub-district designated as the control. The intervention included training of storekeepers to detect and refer clients with chronic cough using predesigned referral letters along with monitoring and supervision. Data from a community based chronic cough survey and an audit of health centre records were used to measure its effectiveness. Focus group discussions and in-depth interviews were carried out to document acceptability of the intervention with the different stakeholders.
Following the intervention, the mean patient delay appeared lower in the intervention than comparison areas (2.14 weeks (SD 5.8) vs 8.8 weeks (SD 15.1)). However, after adjusting for confounding variables this difference was not significant (p = 0.07). After the intervention the proportion of the population diagnosed with smear positive TB in the intervention sites (1.2 per 1000) was significantly higher than in the comparison area (0.6 per 1000, p<0.01) even after adjusting for sex and age. Qualitative findings suggested that (a) the referral letters triggered health workers to ask patients to submit sputum for TB diagnosis (b) the approach may be sustainable as the referral role was linked to the livelihood of the storekeepers.
The study suggests that the referral system with storekeepers is sustainable and effective in increasing smear positive TB case notification. Studies that assess this approach for control of other diseases along with collection of specimens by storekeepers or similar providers are needed.
PLoS ONE 01/2012; 7(9):e39746. · 3.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In Malawi, high case fatality rates in patients with tuberculosis, who were also co-infected with HIV, and high early death rates in people living with HIV during the initiation of antiretroviral treatment (ART) adversely impacted on treatment outcomes for the national tuberculosis and ART programmes respectively. This article i) discusses the operational research that was conducted in the country on cotrimoxazole preventive therapy, ii) outlines the steps that were taken to translate these findings into national policy and practice, iii) shows how the implementation of cotrimoxazole preventive therapy for both TB patients and HIV-infected patients starting ART was associated with reduced death rates, and iv) highlights lessons that can be learnt for other settings and interventions.
District and facility-based operational research was undertaken between 1999 and 2005 to assess the effectiveness of cotrimoxazole preventive therapy in reducing death rates in TB patients and subsequently in patients starting ART under routine programme conditions. Studies demonstrated significant reductions in case fatality in HIV-infected TB patients receiving cotrimoxazole and in HIV-infected patients about to start ART. Following the completion of research, the findings were rapidly disseminated nationally at stakeholder meetings convened by the Ministry of Health and internationally through conferences and peer-reviewed scientific publications. The Ministry of Health made policy changes based on the available evidence, following which there was countrywide distribution of the updated policy and guidelines. Policy was rapidly moved to practice with the development of monitoring tools, drug procurement and training packages. National programme performance improved which showed a significant decrease in case fatality rates in TB patients as well as a reduction in early death in people with HIV starting ART.
Key lessons for moving this research endeavour through to policy and practice were the importance of placing operational research within the programme, defining relevant questions, obtaining "buy-in" from national programme staff at the beginning of projects and having key actors or "policy entrepreneurs" to push forward the policy-making process. Ultimately, any change in policy and practice has to benefit patients, and the ultimate judge of success is whether treatment outcomes improve or not.
BMC Public Health 07/2011; 11:593. · 2.08 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: At the epicentre of the HIV epidemic in Eastern Africa, HIV prevalence has appeared to stabilise in most countries. However, there are indications that the HIV epidemic in Malawi has recently declined.
We analysed sexual behaviour survey data from Malawi between 2000 and 2004 and HIV prevalence data from the national antenatal clinic HIV surveillance system between 1994 and 2007 using a mathematical modelling technique that can identify associations between behaviour change and reductions in incidence.
In Malawi between 2000 and 2004 there were significant reductions in the proportion of 15-19 year olds starting sex, the proportion of men having sex with more than one woman in the previous year and significant increases in condom use by men with multiple partners. In the same period, prevalence dropped from 26% to 15% in urban areas among pregnant women and reduced by 40% among women aged 15-24 years. In the same period, prevalence remained at ∼12% in rural areas. Mathematical modelling suggests that the declines in prevalence in urban areas were associated with the behaviour changes and that, if the changes are maintained, this will have cumulatively averted 140,000 (95% interval: 65,000 to 160,000) HIV infections by 2010.
Changes in sexual behaviour can avert thousands of new HIV infections in mature generalised hyper-endemic settings. In urban Malawi, the reduction in the number of men with multiple partners is likely to have driven the reduction in incidence. Understanding the causes of this change is a priority so that successful programmes and campaigns can be rapidly expanded to rural areas and other countries in the region.
[Show abstract][Hide abstract] ABSTRACT: A cross-sectional cell-to-cell survey was conducted in 18 of 22 prisons in Malawi to determine the period prevalence of smear-positive pulmonary tuberculosis (PTB). In each prison, prisoners were interviewed using a structured questionnaire. Prisoners with cough of >1 week's duration were investigated by sputum smear examination. Of 7661 prisoners, 3887 had cough of > or =1 week, of whom 3794 submitted three sputum specimens: 54 (0.7%) had smear-positive PTB. The prevalence of PTB was higher in large urban prisons (1.1%) than in district prisons (0.3%, P < 0.001). More needs to be done to improve TB control in urban prisons.
The International Journal of Tuberculosis and Lung Disease 12/2009; 13(12):1557-9. · 2.76 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To quantify the likely impact of recent WHO policy recommendations regarding smear microscopy and the introduction of appropriate low-cost fluorescence microscopy on a) case detection and b) laboratory workload.
An audit of the laboratory register in an urban hospital, Lilongwe, Malawi, and the application of a simple modelling framework. The adoption of the new definition of a smear-positive case could directly increase case detection by up to 28%. Examining Ziehl-Neelsen (ZN) sputum smears for up to 10 minutes before declaring them negative has previously been shown to increase case detection (over and above that gained by the adoption of the new case definition) by 70% compared with examination times in routine practice. Three times the number of staff would be required to adequately examine the current workload of smears using ZN microscopy. Through implementing new policy recommendations and LED-based fluorescence microscopy the current laboratory staff complement could investigate the same number of patients, examining auramine-stained smears to an extent that is equivalent to a 10 minutes ZN smear examination.
Combined implementation of the new WHO recommendations on smear microscopy and LED-based fluorescence microscopy could result in substantial increases in smear positive case-detection using existing human resources and minimal additional equipment.
PLoS ONE 01/2009; 4(11):e7760. · 3.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Thyolo district, Malawi.
To report on 1) case fatality among human immunodeficiency virus (HIV) positive tuberculosis (TB) patients while on anti-tuberculosis treatment and 2) whether antiretroviral treatment (ART) initiated during the continuation phase of TB treatment reduces case fatality.
Retrospective cohort analysis.
Comparative analysis of treatment outcomes for TB patients registered between January and December 2004.
Of 983 newly registered TB patients receiving diagnostic HIV testing, 658 (67%) were HIV-positive. A total of 132 (20%) patients died during the 8-month course of anti-tuberculosis treatment, of whom 82 (62%) died within the first 2 months of treatment when ART was not provided (cumulative incidence 3.0, 95%CI 2.5-3.6 per 100 person-years). A total of 576 TB patients started the continuation phase of anti-tuberculosis treatment, 180 (31%) of whom were started on ART. The case-fatality rate per 100 person-years was not significantly different for patients on ART (1.0, 95%CI 0.6-1.7) and those without ART (1.2, 95%CI 0.9-1.7, adjusted hazard ratio 0.86, 95%CI 0.4-1.6, P = 0.6)
ART provided in the continuation phase of TB treatment does not have a significant impact on reducing case fatality. Reasons for this and possible measures to reduce high case fatality in the initial phase of TB treatment are discussed.
The International Journal of Tuberculosis and Lung Disease 09/2007; 11(8):848-53. · 2.76 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To assess the relative costs of accessing a TB diagnosis for the poor and for women in urban Lilongwe, Malawi, a setting where public health services are accessible within 6 kilometers and provided free of charge.
Patient and household direct and opportunity costs were assessed from a survey of 179 TB patients, systematically sampled from all public and mission health facilities in Lilongwe. Poverty status was determined from the 1998 Malawi Integrated Household Survey (MIHS).
On average, patients spent US$ 13 (MK 996 or 18 days' income) and lost 22 days from work while accessing a TB diagnosis. For non-poor patients, the total costs amounted to 129% of total monthly income, or 184% after food expenditures. For the poor, this cost rose to 248% of monthly income or 574% after food. When a woman or when the poor are sick, the opportunity costs faced by their households are greater.
Patient and household costs of TB diagnosis are prohibitively high even where services are provided free of charge. In scaling up TB services to reach the Millennium Development Goals, there is an urgent need to identify strategies for diagnosing TB that are cost-effective for the poor and their households.
Bulletin of the World Health Organisation 09/2007; 85(8):580-5. · 5.25 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To develop locally appropriate measures of poverty for the National Tuberculosis Programme (NTP), Malawi, and to assess access to tuberculosis (TB) services by different socio-economic groups by establishing a socio-economic profile of current TB patients
A quantitative proxy measure of poverty was developed through regression analysis of data from the 1998 national Malawi Integrated Household Survey. A qualitative assessment of poverty was conducted in poor and non-poor settlements in urban Lilongwe to identify key indicators of socio-economic status. Both quantitative and qualitative indicators were used to assess the socioeconomic status of 179 TB patients who participated in a cross-sectional survey.
The proxy measure of poverty and the qualitative indicators demonstrated similar ability to measure the poverty status of patients. The poverty head count among patients using the quantitative and qualitative indicators were 78% and 70%, respectively. Geographical analysis showed that 60% were from non-poor areas and only 15% (26/139) were from squatter settlements.
This study established a strategy for monitoring access to TB services using a proxy measure of poverty and qualitative indicators. This is a vital first step in developing an evidence base for pro-poor equitable TB services.
The International Journal of Tuberculosis and Lung Disease 02/2007; 11(1):65-71. · 2.76 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A decade ago the problem of TB in Africa attracted little attention, not even meriting a chapter in the first edition of Disease and Mortality in Sub-Saharan Africa. Part of the reason was that TB incidence was low and falling in most parts of the continent (Cauthen, Pio, and ten Dam 2002). The burden of TB in Sub-Saharan Africa is far greater today. Continuing poverty and political instability in parts of the continent has inhibited progress in implementing effective TB control measures. But the principal reason for the resurgence of TB in Africa is not the deterioration of control programs. Rather, it is the link between TB and the human immunodeficiency virus and the acquired immune deficiency syndrome (HIV/AIDS). People who are latently infected with Mycobacterium tuberculosis—about one-third of the inhabitants of Sub-Saharan Africa (Dye et al. 1999)—are at hugely greater risk of developing active TB if they are also immunologically weakened by a concurrent HIV infection. HIV-positive people are also more likely to develop TB when newly infected or reinfected with M. tuberculosis. Over the past decade, the TB caseload has increased by a factor of five or more in those countries of eastern and southern Africa that are most affected by HIV. Incidence rates in these countries are now comparable with those recorded in Europe half a century ago, before the introduction of antituberculosis drugs.
Disease and Mortality in Sub-Saharan Africa, 2nd edited by Dean T Jamison, Richard G Feachem, Malegapuru W Makgoba, Eduard R Bos, Florence K Baingana, Karen J Hofman, Khama O Rogo, 01/2006: chapter Chapter 13; World Bank., ISBN: 0821363972
[Show abstract][Hide abstract] ABSTRACT: The rapid and massive scale-up of antiretroviral drug therapy (ART) so needed in sub-Saharan Africa will not be possible using a 'medicalised' model. A more simple approach is required. DOTS has been used now for many years to provide successful anti-tuberculosis treatment to millions of patients in poor countries of the world, and many of the established concepts can be used for the delivery of ART. Malawi, a small and impoverished country in sub-Saharan Africa, is embarking on a national scale-up of ART. In this review we describe how we have adopted several of the principles of DOTS for delivering ART in Malawi: case finding and registration, treatment, monitoring, drug procurement, staffing and the issue of free drugs. We also discuss ART for HIV-infected TB patients. We hope that by using the DOTS approach we will be able to deliver ART to large numbers of HIV-infected patients under controlled conditions, and minimise the risk of developing drug resistance.
The International Journal of Tuberculosis and Lung Disease 11/2005; 9(10):1062-71. · 2.76 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The rapid and massive scale-up of antiretroviral drug therapy (ART) so needed in sub-Saharan Africa will not be possible using a medicalised model. A more simple approach is required. DOTS has been used now for many years to provide successful anti-tuberculosis treatment to millions of patients in poor countries of the world, and many of the established concepts can be used for the delivery of ART. Malawi, a small and impoverished country in sub-Saharan Africa, is embarking on a national scale-up of ART. In this review we describe how we have adopted several of the principles of DOTS for delivering ART in Malawi: case finding and registration, treatment, monitoring, drug procurement, staffing and the issue of free drugs. We also discuss ART for HIV-infected TB patients. We hope that by using the DOTS approach we will be able to deliver ART to large numbers of HIV-infected patients under controlled conditions, and minimise the risk of developing drug resistance.
The International Journal of Tuberculosis and Lung Disease 09/2005; 9(6 in the series" class="no-underline contain" target="_blank">PDF 510.4kb):1062-1071. · 2.76 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Two country-wide surveys were undertaken to assess progress in scaling up human immunodeficiency virus/ acquired immune-deficiency syndrome (HIV/AIDS) and HIV-tuberculosis (TB) services in the public health sector in Malawi between 2002 and 2003. In 2003, 118 sites were performing counselling and HIV testing compared with 70 in 2002. There were 215 269 HIV tests carried out in 2003 compared with 149 540 in 2002, the largest increases being in pregnant women (from 5059 to 26791), patients with TB (from 2130 to 3983) and patients/clients attending health facilities (from 35 407 to 79 584). In 2003, 3703 patients with AIDS were started on antiretroviral therapy compared with 1220 patients in 2002.
The International Journal of Tuberculosis and Lung Disease 06/2005; 9(5):582-4. · 2.76 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Scaling up of counselling and HIV testing (VCT) services requires a system of regular monitoring and evaluation. AVCT monitoring tool was developed through a consultative process and used to assess counselling and HIV testing services in 16 government and mission hospitals in Malawi, which had started expanded HIV-TB activities in July 2003. The essential components of theVCT monitoring tool included assessments of: (i) the hospital VCT personnel, in particular the number of counsellors (full-time and part-time) and those trained in and performing whole blood rapid HIV testing; (ii) the hospital laboratory service, in particular the protocols for HIV testing; (iii) the number, structure and function of dedicated VCT rooms; (iv) registers for patients, clients and donors having HIV tests; and (v) the quality of VCT through structured interviews with HIV-positive patients with TB. The main findings were: 9644 patients and clients were HIV tested between July and September 2003; HIV testing protocols were not standardized and differed between hospitals; there was little in the way of external quality assurance and there were deficiencies in the counselling process. In each hospital, the mean time taken to obtain the data and complete theVCT monitoring tool was 3 h. TheVCT monitoring tool is straightforward to use, and the data collected should help to improve standardization, quality and future planning of VCT services in the country.
Tropical Doctor 05/2005; 35(2):72-5. · 0.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In a study conducted in the medical wards of Lilongwe Central Hospital, Malawi, 84 (18%) of 470 medical admissions were TB suspects. Of these, 21 (25%) had the diagnosis confirmed; the median length of time between admission and starting anti-TB treatment was 10 days. Of the remaining TB suspects, 24 (29%) had another diagnosis made, principally pneumonia, and 39 (46%) had no diagnosis made, with half of these patients dying under investigation in hospital. Improved and more rapid ways of managing TB suspects need to be found.
Tropical Doctor 05/2005; 35(2):93-5. · 0.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Two country-wide surveys were undertaken to assess progress in scaling up human immunodeficiency virus/acquired immune-deficiency syndrome (HIV/AIDS) and HIV-tuberculosis (TB) services in the public health sector in Malawi between 2002 and 2003. In 2003, 118 sites were performing counselling and HIV testing compared with 70 in 2002. There were 215269 HIV tests carried out in 2003 compared with 149540 in 2002, the largest increases being in pregnant women (from 5059 to 26791), patients with TB (from 2130 to 3983) and patients/clients attending health facilities (from 35407 to 79584). In 2003, 3703 patients with AIDS were started on antiretroviral therapy compared with 1220 patients in 2002.
The International Journal of Tuberculosis and Lung Disease 04/2005; 9(5):582-584. · 2.76 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The World Health Organization (WHO) has set a target of treating 3 million people with antiretroviral treatment (ART) by 2005. In sub-Saharan Africa, HIV-positive tuberculosis (TB) patients could significantly contribute to this target. ART (stavudine/lamivudine/nevirapine) was initiated in Thyolo district, Malawi, in April 2003, and all HIV-positive TB patients were considered eligible and offered ART. Despite this, only 44 (13%) of 352 TB patients were eventually started on ART by the end of November 2003. Most TB patients leave hospital after 2 weeks to complete the initial phase of anti-tuberculosis treatment (rifampicin-based) in the community, and ART is offered to HIV-positive TB patients after they have started the continuation phase of treatment (isoniazid/ ethambutol). ART is only offered at hospital, while the majority of TB patients take their continuation phase of anti-tuberculosis treatment from health centres. HIV-positive TB patients therefore find it difficult to access ART. In this paper, we discuss a series of options to increase the uptake of ART among HIV-positive TB patients. The main options are: 1) to hospitalise HIV-positive TB patients with a view to starting ART in the continuation phase in hospital; 2) to decentralise ART delivery so ART can be delivered at health centres; 3) to replace nevirapine with efavirenz so ART can be started earlier in the initial phase of anti-tuberculosis treatment. Decentralisation of ART from hospitals to health centres would greatly improve ART access.
The International Journal of Tuberculosis and Lung Disease 04/2005; 9(3):238-47. · 2.76 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The global targets for tuberculosis (TB) control were postponed from 2000 to 2005, but on current evidence a further postponement may be necessary. Of the constraints preventing these targets being met, the primary one appears to be the lack of adequately trained and qualified staff. This paper outlines: 1) the human resources and skills for global TB and human immunodeficiency virus (HIV) TB control, including the human resources for implementing the DOTS strategy, the additional human resources for implementing joint HIV-TB control strategies and what is known about human resource gaps at global level; 2) the attempts to quantify human resource gaps by focusing on a small country in sub-Saharan Africa, Malawi; and 3) the main constraints to human resources and their possible solutions, under six main headings: human resource planning; production of human resources; distribution of the work-force; motivation and staff retention; quality of existing staff; and the effect of HIV/AIDS. We recommend an urgent shift in thinking about the human resource paradigm, and exhort international policy makers and the donor community to make a concerted effort to bridge the current gaps by investing for real change.
The International Journal of Tuberculosis and Lung Disease 03/2005; 9(2):128-37. · 2.76 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: National Tuberculosis (TB) Control Programme (NTP), Malawi.
To determine the feasibility and effectiveness of performance-related allowances for NTP personnel working at central and regional levels in Malawi. In particular, to determine 1) whether programme staff can complete 6-monthly self-assessment forms related to the tasks they are expected to perform during that period, and 2) whether the NTP can achieve four key programme targets related to case finding, treatment outcome and the sending of sputum specimens for drug resistance monitoring.
A descriptive study.
For January to June 2003, 25 personnel completed self-assessment forms, and in all cases individual performance was judged satisfactory. For July to December 2003, 21 personnel completed self-assessment forms, and in 20 cases individual performance was judged satisfactory. In the first quarter of 2003, only one target was achieved for the country, and NTP personnel were awarded one quarter of the performance payment. In the third quarter, two targets were achieved and NTP personnel were awarded one half of the performance payment.
It is feasible to implement performance-related payments for NTP personnel. Ways to routinely introduce such a system for NTP and other staff in the health sector urgently need to be explored.
The International Journal of Tuberculosis and Lung Disease 03/2005; 9(2):138-44. · 2.76 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Thyolo district, Malawi.
To determine in HIV-positive individuals aged over 13 years CD4 lymphocyte counts in patients classified as WHO Clinical Stage III and IV and patients with active and previous tuberculosis (TB).
CD4 lymphocyte counts were determined in all consecutive HIV-positive individuals presenting to the antiretroviral clinic in WHO Stage III and IV.
A CD4 lymphocyte count of < or = 350 cells/microl was found in 413 (90%) of 457 individuals in WHO Stage III and IV, 96% of 77 individuals with active TB, 92% of 65 individuals with a history of pulmonary TB (PTB) in the last year, 91% of 89 individuals with a previous history of PTB beyond 1 year, 81% of 32 individuals with a previous history of extra-pulmonary TB, 93% of 107 individuals with active or past TB with another HIV-related disease and 89% of 158 individuals with active or past TB without another HIV-related disease.
In our setting, nine of 10 HIV-positive individuals presenting in WHO Stage III and IV and with active or previous TB have CD4 counts of < or = 350 cells/microl. It would thus be reasonable, in this or similar settings where CD4 counts are unavailable for clinical management, for all such patients to be considered eligible for antiretroviral therapy.
The International Journal of Tuberculosis and Lung Disease 03/2005; 9(3):258-62. · 2.76 Impact Factor