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, MalawiMinistry of Health and Population, Malawi

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!

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”

Staff per 100,000 population

(WHO, 2004)

Cadre South-Africa

Lesotho Malawi Mozam-bique

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 146,411• HIV-positive 36, 603• PLWA counsellors 124,449

(>85%)• Over three quarters of all CT in the district

done by PLWA counsellors !

CT: Average/Month Thyolo, Malawi

0

1000

2000

3000

4000

5000

6000

2003 2004 2005 2006

HIV testing

“Task shifting” : Nurses to PLWA’s

Task shifting increased CT capacity by 5 times

RESULTS (2) Consultations / Month

0

500

1000

1500

2000

2500

3000

3500

4000

4500

2004 2005 2006 2006

Consultations

Task shifting to medical assistants, nurses & PLWA’s Partial task shifting to medical assistants

Three health centres ++

RESULTS (3)ART: New inclusions/Month

0

50

100

150

200

250

300

350

400

2004 2005 2006 2006

ART Inclusions

Three health centres ++

“Partial” task shifting to medical assistants

Task shifting to medical assistants, nurses & PLWA’s

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) 806 No with Smear + PTB 161 (20%)Annual TB incidence (Households) 1997/100,000Reported TB incidence (Malawi) 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 1634 • with community support 895

(55%)• without community support 739

(45%)

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….