Providing universal access to antiretroviral therapy in Thyolo, Malawi through task shifting and decentralization of HIV/AIDS care

Médecins Sans Frontières, Blantyre, Malawi.
Tropical Medicine & International Health (Impact Factor: 2.33). 10/2010; 15(12):1413-20. DOI: 10.1111/j.1365-3156.2010.02649.x
Source: PubMed


To describe how district-wide access to HIV/AIDS care was achieved and maintained in Thyolo District, Malawi.
In mid-2003, the Ministry of Health and Médecins Sans Frontières developed a model of care for Thyolo district (population 587, 455) based on decentralization of care to health centres and community sites and task shifting.
After delegating HIV testing and counseling to lay counsellors, uptake of testing increased from 1300 tests per month in 2003 to 6500 in 2009. Shifting responsibility for antiretroviral therapy (ART) initiations to non-physician clinicians almost doubled ART enrollment, with a majority of initiations performed in peripheral health centres. By the end 2009, 23, 261 people had initiated ART of whom 11, 042 received ART care at health-centre level. By the end of 2007, the universal access targets were achieved, with nearly 9000 patients alive and on ART. The average annual cost for achieving these targets was € 2.6 per inhabitant/year.
The Thyolo programme has demonstrated the feasibility of district-wide access to ART in a setting with limited resources for health. Expansion and decentralization of HIV/AIDS service-capacity to the primary care level, combined with task shifting, resulted in increased access to HIV services with good programme outcomes despite staff shortages.

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Available from: Beatrice Mwagomba
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    • "Within each hospital, an ART clinic provides outpatient care for patients with HIV or autoimmune deficiency syndrome (AIDS) on schedules ranging from two to five days per week, depending on the demand for ART services at the hospital. Staff who are trained to initiate and provide ART are mid-level healthcare providers, including clinical officers, nurses, and certified nursemidwives [33]. In Malawi's district hospitals, like hospitals in many low-income countries, care is routinely provided without physician oversight or on-site consultation services due to critical shortages of healthcare providers [34]. "
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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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    • "Generally, the effectiveness of scale-up programmes involving CHWs has been difficult to determine given the variation in the scale-up approach and the difficulties measuring outcomes [5-8,17]. However, locally the Médecins Sans Frontières experience in Thyolo district Malawi provides some evidence of feasibility and good outcomes for a programme of decentralized HIV care to clinics and community settings using task-shifting in which HSAs provided the HIV testing and counselling, and, treatment initiation was transferred to non-physician clinicians [18]. Between 2003 and 2009, the programme achieved universal access targets and achieved significant gains in human resources efficiency [18]. "
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