Transcript Does community support influence antiretroviral treatment

Task-Shifting in HIV/AIDS Care in a
Rural District
of Malawi
Some successes and lessons learnt from
Thyolo
Moses Massaquoi, Rony Zachariah, Ulrike von Pilar
Médecins Sans Frontières (Operational research) –
Brussels
District Health Services, Thyolo, Malawi
Ministry of Health and Population, Malawi
MALAWI
•
•
•
•
•
•
•
Population
Adult prevalence
HIV-infected people
Life expectancy
TB cases/year
Hospital admissions
HIV/AIDS - deaths/year
13 million
14,1%
900,000
39 yrs
25, 000 (77%HIV+)
70% HIV+
90,000
HIV/AIDS & TB: A major burden on
health services!
MALAWI
Shortage of health staff
• Vacant positions:
• Nursing staff
• Clinical officers
• Doctors / Specialists
64%
53%
85-100%
• Nurse/health facility
• < 1.5 nurses per health facility in 15/29
districts
• Doctors/district
• 10 districts with no MOH doctor.
• 4 districts have no doctor at all
“2004: “Crisis” / Collapse of the health sector”
Staff per 100,000
population
(WHO, 2004)
Cadre
SouthAfrica
Lesotho
Malawi
Mozambique
USA
UK
Doctors
74,3
5
2
2.6
247
222
Nurses
393
62.6
56.4
20
901
1,170
Background: Thyolo district
OBJECTIVES
To highlight some successes and
lessons learnt in “task
shifting” to achieve Universal
ART Access in Thyolo.
METHODS (1)
Scale up: HIV-testing/ Clinic
services
CT:
• Increase sites: from 3 to 26
(trained lay PLWA counsellors)
HIV/AIDS clinics:
• Drastically improve efficiency of
“delivery systems” particularly for
ART.
METHODS (2) : Clinics
“One track” doctor centred  “multiple
flow tracks”
• Screening & track allocation - Nurse
• Slow track
- Medical assistant
• Complicated opportunistic infections (OI)
• Side effects/referred patients
• Medium track - Nurse
• Less severe OI (eg candida, diarrhoea)
• ART initiation /ART follow up (< 1month)
• Fast track - PLWA counsellor
• Stable patients & drug refills
Doctor/Clinical officer – Supervision and
support
METHODS (3)
Community: Involvement & Activities
Community network :
(Volunteers/PLWA’s)
–
–
–
–
–
–
Treatment : diarrhoea, fever, oral thrush….
Community based counselling (ART)
Support to family care givers at home
Referral : drug reactions and “risk signs”.
Cough screening (TB)
Social mobilisation.
METHODS (4)
Community: Volunteers
METHODS (5)
Community: Home care “kit”
METHODS (6)
Community: Nurses
RESULTS (1)
HIV- testing
Period Jan 2003 – Dec 2006
•
•
•
HIV-tested
HIV-positive
PLWA counsellors
(>85%)
146,411
36, 603
124,449
• Over three quarters of all CT in the district
done by PLWA counsellors !
CT: Average/Month
Thyolo, Malawi
“Task shifting” : Nurses to PLWA’s
6000
5000
4000
3000
HIV testing
2000
1000
0
2003
2004
2005
2006
Task shifting increased CT capacity by 5 times
RESULTS (2)
Consultations / Month
Partial task shifting to
medical assistants
Task shifting to medical assistants, nurses & PLWA’s
Three health centres ++
4500
4000
3500
3000
2500
Consultations
2000
1500
1000
500
0
2004
2005
2006
2006
RESULTS (3)
ART: New inclusions/Month
“Partial” task shifting to
medical assistants
Task shifting to medical assistants, nurses & PLWA’s
Three health centres ++
400
350
300
250
200
ART Inclusions
150
100
50
0
2004
2005
2006
2006
Task shifting increased ART inclusion capacity by 4 times
ART - Thyolo
Universal Access - Dec 2007 ?
•
•
•
•
ART Target:
10,000 (+-1000)
On ART
6285 (March 2007)
ART initiations/Month 400
Target
Nov 2007
Without task shifting, this target would
only have been achieved by 2012 !
RESULTS (4)
Community: Active TB case finding
(Jan 2003-Dec 2004)
Chronic cough:  3 weeks
No referred (chronic cough)
No with Smear + PTB
Annual TB incidence (Households)
Reported TB incidence (Malawi)
806
161 (20%)
1997/100,000
265/100,000
“Active” cough screening detects 8 times more
infectious TB cases !
RESULTS (5)
Antiretroviral treatment (ART)
Period Jan 2003-Dec 2004
• Total placed on ART
• with community support
(55%)
• without community support
(45%)
1634
895
739
Compare: ART outcomes among patients
living in areas with and without community support
CONCLUSIONS (1)
• Universal access: Develop a Public
Health ART scale-up model,
standardize, keep it simple, be
inclusive, use lower cadres &
community.
“Good for many” instead of
“best for a few”
CONCLUSIONS (2)
Be innovative..
Challenge established practices,
rules and regulations
“professional turf protection”
ACKNOWLEDGEMENTS
• PLWA associations and groups
• District health services, Thyolo
• Ministry of Health - Malawi
• Financial support:
– G.D of Luxembourg,
– DFID, NORAD, Global FUND, EU,
USAID, FHI, KNCV TB foundation,
CIFF, WHO STOP-TB….