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

Objective To describe how district-wide access to HIV/AIDS care was achieved and maintained in Thyolo District, Malawi. Method 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. Results 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 enrolment, 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. Conclusion 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. Objectif: Décrire comment l’accès aux soins VIH/SIDA a été atteint et maintenu dans tout le district de Thyolo, au Malawi. Méthode: Au milieu de 2003, le Ministère de la Santé (MS) et Médecins Sans Frontières (MSF) ont développé un modèle de soins pour le district de Thyolo (population 587. 455) fondé sur la décentralisation des soins vers les centres de santé et les sites communautaires et la délégation des tâches. Résultats: Après la délégation du dépistage et conseil à des conseillers, l’adoption du dépistage a augmenté de 1. 300 tests par mois en 2003 à 6. 500 en 2009. Le transfert de la responsabilité pour les initiations de l’ART à des cliniciens non-médecins a presque doublé l’enrôlement à l’ART, avec une majorité des initiations réalisées dans les centres de santé périphériques. À la fin de 2009, 23. 261 personnes avaient débuté l’ART dont 11. 042 recevaient des soins ART au niveau du centre de santé. À la fin de 2007, les objectifs d’accès universel étaient atteints, avec près de 9. 000 patients sous ART et en vie. Le coût moyen annuel pour atteindre ces objectifs était de 2, 6 € par habitant-année. Conclusion: Le programme de Thyolo a démontré la faisabilité de l’accès à l’ART dans tout le district dans un cadre de ressources limitées pour la santé. L’expansion et la décentralisation de la capacité des services VIH/SIDA au niveau des soins primaires, combinée avec la délégation des tâches, a permis un accès accru aux services VIH avec de bons résultats de programme, malgré les pénuries de personnel. Mots clés: accès universel, délégation des tâches, ressources humaines, déploiement de l’ART, décentralisation, Malawi Objetivo: Describir como se consiguió y se mantiene, en todo el distrito de Thyolo, en Malawi, el acceso a los cuidados para el VIH/SIDA. Método: A mediados del 2003, el Ministerio de Salud (MinSal) y Médicos Sin Fronteras (MSF) desarrollaron un modelo de cuidados para el distrito de Thyolo (con una población de 587, 455 habitantes), basado en la descentralización de los cuidados hacia los centros de salud y centros comunitarios, así como con una rotación de las tareas entre el personal sanitario. Resultados: Después de delegar el aconsejamiento y prueba del VIH (ACP) a consejeros civiles, la toma de la prueba aumentó de 1, 300 pruebas al mes en 2003 a 6, 500 en el 2009. La rotación de responsabilidades que permitía a clínicos no médicos iniciar el TAR, casi dobló la inclusión de pacientes en el TAR, con la mayoría de los nuevos comienzos realizados en centros sanitarios periféricos. Al final del 2009, 23, 261 personas habían comenzado TAR, de las cuales 11, 042 recibían los cuidados asociados al TAR a nivel de centros sanitarios. Al final del 2007, se cumplieron los objetivos de acceso universal, con casi 9, 000 pacientes vivos y recibiendo TAR. El coste anual de alcanzar estos objetivos fue de €2. 6 por habitante/año. Conclusión: El programa Thyolo ha demostrado la posibilidad de ofrecer acceso al TAR en todo un distrito y en un emplazamiento con recursos sanitarios limitados. La expansión y descentralización de la capacidad de servicios para el VIH/SIDA hasta el nivel de cuidados primarios, combinado con una rotación de tareas, resultó en un aumento en el acceso a los servicios de VIH y buenos resultados en el programa, a pesar de la escasez de personal sanitario. Palabras clave: acceso universal, rotación de tareas, recursos humanos, TAR, descentralización, Malawi Malawi (population 13 million) is a small, very poor country with an adult HIV prevalence estimated at 12% (Ministry of Health 2008). Despite a dire shortage of health workers and a high level of poverty per capita Gross Domestic Product (GDP) is US596, the government of Malawi has made tremendous efforts to scale up HIV care and treatment (Nkandu et al. 2005, National AIDS Commission, 2010). The country embarked on a national scale-up of antiretroviral therapy (ART) in 2004, at a time when an estimated 170 000 people were in need of treatment (Libamba et al. 2007). A model of care was developed that relied on non-physician clinicians, nurses and lay workers to deliver ART, and this public health approach has enabled 271 105 people to have started ART via 377 facilities as of end 2009 (Ministry of Health 2009), among whom 198 846 (73%) were alive and on ART. This represented almost two-thirds of the need (306 000 people) (Ministry of Health 2008), putting Malawi ahead of other countries in the region in terms of ART coverage. South Africa for example had a GDP per capita more than 16 times that of Malawi, yet ART coverage in 2009 was substantially lower, estimated at just 40% (Adam decentralization of care to health centres and community sites to spread the workload across multiple sites and increase access; simplification of protocols for testing and treatment; community engagement to increase capacity and support programme sustainability; and strengthening the health system. These different approaches are outlined below. Malawi has faced a considerable loss of health workers, mainly because of employment opportunities in other countries and loss of staff because of HIV/AIDS (Harries et al. 2002). At the end of 2007, the national Human Resources for Health census reported that there were only 159 doctors (1/100 000 pop) and 3614 nurses/midwifes/nurse-technicians (26/100 000 pop) in the country. These rates are among the lowest in the region (Ministry of Health 2007). Primary health facilities in rural areas are generally staffed by nurses and medical assistants, a cadre of non-physician clinicians with basic 2-year training. Only 32% of health centres in Malawi fulfil the agreed staffing norms described in the Essential Health Package of two nurses/midwives and one medical assistant or clinical officer. Table 1 summarizes the main cadres providing HIV/AIDS care in Thyolo district. On average, 1. 1 Full Time Equivalent (FTE) clinical officers or medical assistants and 1. 24 FTE nurses and 1. 2 FTE clerks provide ART care for approximately 1000 patients on ART in the country (Ministry of Health 2009). In Thyolo District Hospital, between 2005 and 2007, the total number of staff per 1000 patients on ART was calculated to be approximately four FTEs (1. 4 clinical staff, 0. 25 pharmacy staff, 0. 8 counsellors and 1. 5 non-medical staff). These figures are all far below the minimum of seven FTEs per 1000 patients on ART recommended by WHO (Hirschhorn et al. 2006). Because of these critical human resource shortages, ‘task shifting’ has been promoted as an essential component of ART scale-up to overcome the shortage of doctors and other essential health staff in the country (World Health Organization 2008). Task shifting entails the delegation of certain medical responsibilities to less specialized health workers. The effectiveness of such delegation has since been supported by a number of studies from Malawi (Ferradini et al. 2006) and elsewhere in southern Africa (Callaghan et al. 2010). Examples of task shifting applied in Thyolo are summarized in Table 2. As only one in five medical doctors work in district hospitals (Ministry of Health 2007), Ministry of Health guidelines allow non-physician clinicians and nurses to initiate ART. ART skills are transferred during a 1-week classroom training course, combined with a 2-week clinical attachment in an experienced ART site. Successful participants receive a certificate of competence. Clinical supervision by a team of experienced clinicians takes place regularly. In April 2003, initiation of patients on ART started at the district hospital, mainly by clinical officers. Task shifting ART care from clinical officers to medical assistants took place soon after, resulting in the possibility to decentralize ART initiations to health centres. In 2007, the policy was further revised to allow nurses to start patients on ART. Health Surveillance Assistants (HSAs) have played a crucial role in the decentralized district health system. This cadre was initially created as a community cadre responsible for preventive activities and organizing disease outbreak response. HSAs follow a 10-week basic training and their numbers can therefore be increased relatively rapidly and at low cost. After an increase in training of HSAs in 2007, coverage of HSAs rose from 5040 in 2006 to 11 000 in 2007 with almost approximately one HSA per 1200 population today. Another important adaptation was the shifting of HIV testing and counseling (HTC) from nurses to trained HSA counsellors. After undergoing a 3-week formal training, HSA counsellors are certified by the MoH to conduct HTC. Remuneration remains at the same level as for other HSAs. These HSA counsellors currently spend several days per week at the health facility providing HTC services. More than 2000 HSA counsellors are now engaged in HTC activities (National AIDS Commission 2010). At Thyolo District Hospital, patients are triaged by a nurse and directed to different health providers according to their clinical status and duration on ART. Patients with complications enter the ‘slow track’ and receive comprehensive care and treatment from an experienced clinician (medical assistant or clinical officer) ; new patients and those with relatively mild problems are managed by a clinician in the ‘medium track’; stable patients (defined as those on ART for more than 2 months and without clinical complications) are followed up in the ‘fast track’ and seen by a nurse. The average number of consultations per health care provider is 210/month for the slow track, 680/month for the medium track and 2100/month for the fast track. An average fast track consultation takes approximately 10 min, while a visit in the slow track by a clinician takes between 20 and 30 min. As a result of these service adaptations, the number of patients enrolled onto ART treatment almost doubled from 130 to 250 patients per month in the hospital, and the median time in starting ART for eligible patients fell from 98 days in 2003 to less than 20 days in 2009. A similar model of patient management is in operation at the health centres. Prior to the introduction of ART in 2003, considerable numbers of patients were bedridden, receiving palliative care and other basic support from community home-based care givers (nurses and volunteers). In addition, efforts of these community care givers included HIV/AIDS awareness campaigns and prevention activities such as condom distribution. A number of activities made use of support groups formed by HIV-positive people at community level. The contribution of these support structures intensified with the introduction of ART as support groups started encouraging early treatment-seeking behaviour and long-term adherence to treatment. Studies have shown that community support can lead to better adherence (Weidle et al. 2006), higher retention in care (Torpey et al. 2008) and increased survival (Zachariah et al. 2007). At the end of 2008, over 9000 patients – 67% of the total ART cohort – were registered within the community support network. In 2009, community support was further expanded through the establishment of improved health posts (IHPs) serving a catchment population between 5000 and 15 000 and staffed by a community nurse visiting once or twice per month, two or three HSAs and three ‘patient support attendants’ (adherence supporters/peer counsellors). These health posts provide a minimum package of HIV services, including HTC. People testing HIV positive undergo systematic screening for opportunistic infections and are staged by the community nurse according to WHO clinical criteria. Among those in WHO Stage I and II, blood samples are taken for CD4 counts to determine ART eligibility. According the national guidelines, patients in WHO Stage III and IV and those with a CD4 count below 250 cells/mm3 are referred to the nearest suitable site for ART initiation, after having attended individual and group counselling sessions at the IHP. After an initial follow-up period at a health centre or district hospital, patients without complications may receive refills of ART at the IHP. By providing pre-ART and ART care close to patients’ homes, IHPs aim to enhance retention in care and decongest the health centres. More recently, a range of essential non-HIV services has been made available at the post, including family planning and care for chronic diseases (epilepsy, and and treatment be in the and 2000 consultations place on a in IHPs and in 20 community of the patient on health centres. On average, patients per month are to the initiation for an of pre-ART group counselling care in health centres et al. 2009). As of end of 2009, in to the two ART initiation had been decentralized to seven peripheral health centres up to from the district A total of sites Health five follow-up ART care after the initiation As a the of the ART cohort followed up at level has over the performed in 2006 and 2007 compared patient outcomes between those started ART in the and those started in a health rates after 1 on ART were for and health centres. to follow-up were in health centres compared to was higher et al. 2009). The shifting of HTC from nurses to trained HSA counsellors supported an increase in testing capacity from sites at the end of 2003 an average of tests per month performed at to sites at the end of 2009 tests per site per The of patients testing positive from in 2003 to in 2009 as a result of the coverage. to HIV testing and The delegation of ART initiation and follow-up from doctors to clinical officers and medical assistants more than the number of new from per month in ART initiation was available only at the district to per month in 2009 per month in the district ART initiation in In addition, patients received ART at the district were transferred to health centres for follow-up treatment. to antiretroviral therapy in Thyolo medical 2003 and 2009, a total of 23 261 patients started ART. As of end 2009, were reported alive and in had been transferred out to other had and treatment. This with other ART in the region et al. 2006). rates were similar between primary and level, were higher in compared with health centres the health improved coverage has patients to start treatment at a higher CD4 count from cells/mm3 in 2003 to cells/mm3 in 2009. Time to initiation from nearly days in 2003 to less than three in 2009. This have an important on survival et al. et al. for district-wide universal access in Thyolo were calculated on the of available and ART need was estimated at 11 patients in 2007 and 250 in 2009. 9000 patients were receiving ART in 2007 and over 000 in 2009. the of universal access as of the this that universal access was achieved in 2007 et al. 2008) and has far been that these were from by the Ministry of Health at the more have since been developed to the number of people in need of such as of people on treatment and population By task shifting and the of an number of patients were to access ART and other services with only a relatively increase in the total number of health on an average HTC time of min, task shifting of the 6500 tests performed month in the district from nurses to resulted in per month to FTE Task shifting of ART refills and adherence counselling task time 15 to HSAs in Health a of medical time to three the increased effectiveness of staff over with number of consultations in Thyolo District These have to the of the ART a that the average annual cost for achieving universal access to an €2. 6 per is within the basic health package estimated by yet within the national health per capita et al. 2009). and access to ART in Thyolo district was enabled by a public health approach that task shifting, decentralization and and engaged multiple of health care as as the ART initiations have more than and the time to initiation has the support at community level from palliative care to a on treatment and Task shifting to different cadres of health staff, community workers (HSAs) and workload of clinical staff while to a more of services. Despite these the human resource remains critical in Thyolo and it is that further task shifting need to be as the model be to ART coverage in the of the the engagement of nurses in ART initiation limited by the number of nurses and and the delegation of more to patients and community support Malawi the of to the of access to improved ART while having to follow-up and care for those on including those WHO initiation of ART 2009), and this is estimated to increase the number of people eligible for treatment by (Ministry of Health on task shifting and of ART while patients in care to be in Thyolo and in Malawi as a The policy is to initiate all on ART of clinical or These with a of people alive on ART – approximately of the adult population is currently on ART and this is to in the 10 – are estimated to staff for the country as a (Ministry of Health Task shifting a in Malawi, to the on HIV services. task shifting be seen as a of an has to to increase and and new cadres of staff et al. 2008). in Thyolo District and support for as as supervision The of support for people on ART need to over time as patients new to long-term adherence and retention in of support need to be at the community level to as as that ART care is made to than people to their ART. Clinical can also be to over time of long-term that supervision of health care at the peripheral level. long-term support for treatment. all for and for is by the while all are by support need to be for the in of the that Malawi has to national guidelines in with the WHO to in the and initiate treatment from Thyolo Malawi, over the that universal access to ART can be achieved and in rural Task shifting is a to support increased access to ART care in human resources for health care are The decentralization of care from to health centre level can be achieved in a that primary health care services programme to support the further of ART coverage while long-term for those receiving treatment and supervision of staff are and decentralization of ART care can be applied with programme outcomes to and for during the of this