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Médecins Sans Frontières (Operational research) – Brussels

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

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Médecins Sans Frontières (Operational research) – Brussels

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  1. Task-Shifting in HIV/AIDS Care in a Rural District of MalawiSome 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

  2. MALAWI • Population 13 million • Adult prevalence 14,1% • HIV-infected people 900,000 • Life expectancy 39 yrs • TB cases/year 25, 000 (77%HIV+) • Hospital admissions 70% HIV+ • HIV/AIDS - deaths/year 90,000 HIV/AIDS & TB: A major burden on health services!

  3. MALAWIShortage of health staff • Vacant positions: • Nursing staff 64% • Clinical officers 53% • Doctors / Specialists 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”

  4. Staff per 100,000 population(WHO, 2004)

  5. Background: Thyolo district

  6. OBJECTIVES To highlight some successes and lessons learnt in “task shifting” to achieve Universal ART Access in Thyolo.

  7. 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.

  8. 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

  9. 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.

  10. METHODS (4)Community: Volunteers

  11. METHODS (5) Community: Home care “kit”

  12. METHODS (6)Community: Nurses

  13. RESULTS (1)HIV- testing Period Jan 2003 – Dec 2006 • HIV-tested 146,411 • HIV-positive 36, 603 • PLWA counsellors 124,449 (>85%) • Over three quarters of all CT in the district done by PLWA counsellors !

  14. CT: Average/Month Thyolo, Malawi “Task shifting” : Nurses to PLWA’s Task shifting increased CT capacity by 5 times

  15. RESULTS (2) Consultations / Month Task shifting to medical assistants, nurses & PLWA’s Partial task shifting to medical assistants Three health centres ++

  16. RESULTS (3)ART: New inclusions/Month Task shifting to medical assistants, nurses & PLWA’s “Partial” task shifting to medical assistants Three health centres ++ Task shifting increased ART inclusion capacity by 4 times

  17. 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 !

  18. RESULTS (4)Community: Active TB case finding(Jan 2003-Dec 2004) Chronic cough:  3 weeks No referred (chronic cough) 806 No with Smear + PTB 161 (20%) Annual TB incidence (Households) 1997/100,000 Reported TB incidence (Malawi) 265/100,000 “Active” cough screening detects 8 times more infectious TB cases !

  19. RESULTS (5) Antiretroviral treatment (ART) Period Jan 2003-Dec 2004 • Total placed on ART 1634 • with community support 895 (55%) • without community support 739 (45%) Compare: ART outcomes among patients living in areas with and without community support

  20. 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”

  21. CONCLUSIONS (2) Be innovative.. Challenge established practices, rules and regulations “professional turf protection”

  22. 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….

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