Journal Article > ResearchFull Text
Trop Med Int Health. 2010 December 1; Volume 15 (Issue 12); DOI:10.1111/j.1365-3156.2010.02649.x
Bemelmans M, van den Akker T, Ford NP, Philips M, Zachariah R, et al.
Trop Med Int Health. 2010 December 1; Volume 15 (Issue 12); DOI:10.1111/j.1365-3156.2010.02649.x
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.
Journal Article > ReviewFull Text
J Int AIDS Soc. 2016 May 13; Volume 19 (Issue 1); DOI:10.7448/IAS.19.1.20751
Bemelmans M, Baert S, Negussie E, Bygrave H, Biot M, et al.
J Int AIDS Soc. 2016 May 13; Volume 19 (Issue 1); DOI:10.7448/IAS.19.1.20751
Introduction: Counselling services are recommended by the World Health Organization and have been partially adopted by national HIV guidelines. In settings with a high HIV burden, patient education and counselling is often performed by lay workers, mainly supported with international funding. There are few examples where ministries of health have been able to absorb lay counsellors into their health systems or otherwise sustain their work. We document the role of lay cadres involved in HIV testing and counselling and adherence support and discuss approaches to sustainability. Methods: We focused on a purposive sample of eight sub-Saharan African countries where Médecins Sans Frontières supports HIV programmes: Guinea, Lesotho, Malawi, Mozambique, South Africa, Swaziland, Zambia and Zimbabwe. We reviewed both published and grey literature, including national policies and donor proposals, and interviewed key informants, including relevant government staff, donors and non-governmental organizations. Results and discussion: Lay counsellors play a critical role in scaling up HIV services and addressing gaps in the HIV testing and treatment cascade by providing HIV testing and counselling and adherence support at both the facility and community levels. Countries have taken various steps in recognizing lay counsellors, including harmonizing training, job descriptions and support structures. However, formal integration of this cadre into national health systems is limited, as lay counsellors are usually not included in national strategies or budgeting. Conclusions: The current trend of reduced donor support for lay counsellors, combined with lack of national prioritization, threatens the sustainability of this cadre and thereby quality HIV service delivery.
Journal Article > ResearchFull Text
J Int AIDS Soc. 2011 January 5; Volume 14 (Issue 1); DOI:10.1186/1758-2652-14-1
Bemelmans M, van den Akker T, Pasulani O, Saddiq Tayub N, Hermann K, et al.
J Int AIDS Soc. 2011 January 5; Volume 14 (Issue 1); DOI:10.1186/1758-2652-14-1
ABSTRACT: BACKGROUND: In Malawi, the dramatic shortage of human resources for health is negatively impacted by HIV-related morbidity and mortality among health workers and their relatives. Many staff find it difficult to access HIV care through regular channels due to fear of stigma and discrimination. In 2006, two workplace initiatives were implemented in Thyolo District: a clinic at the district hospital dedicated to all district health staff and their first-degree relatives, providing medical services, including HIV care; and a support group for HIV-positive staff. METHODS: Using routine programme data, we evaluated the following outcomes up to the end of 2009: uptake and outcomes of HIV testing and counselling among health staff and their dependents; uptake and outcomes of antiretroviral therapy (ART) among health staff; and membership and activities of the support group. In addition, we included information from staff interviews and a job satisfaction survey to describe health workers' opinions of the initiatives. RESULTS: Almost two-thirds (91 of 144, 63%) of health workers and their dependents undergoing HIV testing and counselling at the staff clinic tested HIV positive. Sixty-four health workers had accessed ART through the staff clinic, approximately the number of health workers estimated to be in need of ART. Of these, 60 had joined the support group. Cumulative ART outcomes were satisfactory, with more than 90% alive on treatment as of June 2009 (the end of the study observation period). The availability, confidentiality and quality of care in the staff clinic were considered adequate by beneficiaries. CONCLUSIONS: Staff clinic and support group services successfully provided care and support to HIV-positive health workers. Similar initiatives should be considered in other settings with a high HIV prevalence.
Journal Article > ResearchFull Text
PLOS One. 2010 May 4; Volume 5 (Issue 5); DOI:10.1371/journal.pone.0010452
Mwagomba B, Zachariah R, Massaquoi M, Misindi D, Manzi M, et al.
PLOS One. 2010 May 4; Volume 5 (Issue 5); DOI:10.1371/journal.pone.0010452
BACKGROUND: To report on the trend in all-cause mortality in a rural district of Malawi that has successfully scaled-up HIV/AIDS care including antiretroviral treatment (ART) to its population, through corroborative evidence from a) registered deaths at traditional authorities (TAs), b) coffin sales and c) church funerals. METHODS AND FINDINGS: Retrospective study in 5 of 12 TAs (covering approximately 50% of the population) during the period 2000-2007. A total of 210 villages, 24 coffin workshops and 23 churches were included. There were a total of 18,473 registered deaths at TAs, 15781 coffins sold, and 2762 church funerals. Between 2000 and 2007, there was a highly significant linear downward trend in death rates, sale of coffins and church funerals (X(2) for linear trend: 338.4 P<0.0001, 989 P<0.0001 and 197, P<0.0001 respectively). Using data from TAs as the most reliable source of data on deaths, overall death rate reduction was 37% (95% CI:33-40) for the period. The mean annual incremental death rate reduction was 0.52/1000/year. Death rates decreased over time as the percentage of people living with HIV/AIDS enrolled into care and ART increased. Extrapolating these data to the entire district population, an estimated 10,156 (95% CI: 9786-10259) deaths would have been averted during the 8-year period. CONCLUSIONS: Registered deaths at traditional authorities, the sale of coffins and church funerals showed a significant downward trend over a 8-year period which we believe was associated with the scaling up HIV/AIDS care and ART.
Journal Article > ResearchFull Text
BJOG. 2012 January 18; Volume 204 (Issue 4); DOI:10.1093/infdis/jir093
van den Akker T, Bemelmans M, Ford NP, Jemu M, Diggle E, et al.
BJOG. 2012 January 18; Volume 204 (Issue 4); DOI:10.1093/infdis/jir093
Please cite this paper as: van den Akker T, Bemelmans M, Ford N, Jemu M, Diggle E, Scheffer S, Zulu I, Akesson A, Shea J. HIV care need not hamper maternity care: a descriptive analysis of integration of services in rural Malawi. BJOG 2012;119:431-438. Objective To evaluate the use of reproductive health care and incidence of paediatric HIV infection during the expansion of antiretroviral therapy and services for the prevention of mother-to-child transmission in rural Malawi, and the influence of integration of these HIV-related services into general health services. Design Descriptive analysis. Setting Thyolo District, with a population of 600 000, an HIV prevalence of 21% and a total fertility rate of 5.7 in 2004. Population Women attending reproductive health services care in 2005 and 2010. Methods Review of facility records and databases for routine monitoring. Main outcome measures Use of antenatal, intrapartum, postpartum, family planning and sexually transmitted infection services; incidence of HIV infection in infants born to mothers who received prevention of mother-to-child transmission care. Results There was a marked increase in the uptake of perinatal care: pregnant women in 2010 were 50% more likely to attend at least one antenatal visit (RR 1.50, 95% CI 1.48-1.51); were twice as likely to deliver at a healthcare facility (RR 2.05, 95% CI 2.01-2.08); and were more than four times as likely to present for postpartum care (RR 4.40, 95% CI 4.25-4.55). Family planning consultations increased by 40% and the number of women receiving treatment for sexually transmitted infections doubled. Between 2007 and 2010, the number of HIV-exposed infants who underwent testing for HIV went up from 421 to 1599/year, and the proportion testing positive decreased from 13.3 to 5.0%; infants were 62% less likely to test HIV positive (RR 0.38, 95% CI 0.27-0.52). Conclusions During the expansion and integration of HIV care, the use of reproductive health services increased and the outcomes of infants born to HIV-infected mothers improved. HIV care may be successfully integrated into broader reproductive health services.
Journal Article > ResearchFull Text
Int J Tuberc Lung Dis. 2011 July 1; Volume 15 (Issue 7); 933-937.; DOI:10.5588/ijtld.10.0666
Zachariah R, Bemelmans M, Akesson A, Gomani P, Phiri K, et al.
Int J Tuberc Lung Dis. 2011 July 1; Volume 15 (Issue 7); 933-937.; DOI:10.5588/ijtld.10.0666
OBJECTIVE
To report on the trends in new and recurrent tuberculosis (TB) case notifications in a rural district of Malawi that has embarked on large-scale roll-out of antiretroviral treatment (ART).
METHODS
Descriptive study analysing TB case notification and ART enrolment data between 2002 and 2009.
RESULTS
There were a total of 10 070 new and 755 recurrent TB cases. ART scale-up started in 2003, and by 2007 an estimated 80% ART coverage had been achieved and was sustained thereafter. For new TB cases, an initial increase in case notifications in the first years after starting ART (2002–2005) was followed by a highly significant and sustained decline from 259 to 173 TB cases per 100 000 population (χ2 for trend 261, P < 0.001, cumulative reduction for 2005–2009 = 33%, 95%CI 27–39). For recurrent TB, the initial increase was followed by a significant drop, from 20 to 15 cases/100 000 (χ2 for linear trend = 8.3, P = 0.004, constituting a 25% (95%CI 9–49) cumulative reduction between 2006 and 2009. From 2005 to 2009, ART averted an estimated 1164 (95%CI 847–1480) new TB cases and 78 (95%CI 23–151) recurrent TB cases.
CONCLUSIONS
High ART implementation coverage is associated with a very significant declining trend in new and recurrent TB case notifications at population level.
To report on the trends in new and recurrent tuberculosis (TB) case notifications in a rural district of Malawi that has embarked on large-scale roll-out of antiretroviral treatment (ART).
METHODS
Descriptive study analysing TB case notification and ART enrolment data between 2002 and 2009.
RESULTS
There were a total of 10 070 new and 755 recurrent TB cases. ART scale-up started in 2003, and by 2007 an estimated 80% ART coverage had been achieved and was sustained thereafter. For new TB cases, an initial increase in case notifications in the first years after starting ART (2002–2005) was followed by a highly significant and sustained decline from 259 to 173 TB cases per 100 000 population (χ2 for trend 261, P < 0.001, cumulative reduction for 2005–2009 = 33%, 95%CI 27–39). For recurrent TB, the initial increase was followed by a significant drop, from 20 to 15 cases/100 000 (χ2 for linear trend = 8.3, P = 0.004, constituting a 25% (95%CI 9–49) cumulative reduction between 2006 and 2009. From 2005 to 2009, ART averted an estimated 1164 (95%CI 847–1480) new TB cases and 78 (95%CI 23–151) recurrent TB cases.
CONCLUSIONS
High ART implementation coverage is associated with a very significant declining trend in new and recurrent TB case notifications at population level.
Journal Article > ResearchFull Text
Health Policy Plan. 2015 November 5; Volume 31 (Issue 5); 592-599.; DOI:10.1093/heapol/czv106
Bemelmans M, Goux D, Baert S, van Cutsem G, Motsamai M, et al.
Health Policy Plan. 2015 November 5; Volume 31 (Issue 5); 592-599.; DOI:10.1093/heapol/czv106
Between 2006 and 2011, when antiretroviral therapy (ART) was scaled up in a context of severe human resources shortages, transferring responsibility for elements in human immunodeficiency virus (HIV) care from conventional health workers to lay counsellors (LCs) contributed to increased uptake of HIV services in Lesotho. HIV tests rose from 79 394 in 2006 to 274 240 in 2011 and, in that same period, the number of people on ART increased from 17 352 to 83 624. However, since 2012, the jobs of LCs have been at risk because of financial and organizational challenges. We studied the role of LCs in HIV care in Lesotho between 2006 and 2013, and discuss potential consequences of losing this cadre. Methods included a case study of LCs in Lesotho based on: (1) review of LC-related health policy and planning documents, (2) HIV programme review and (3) workload analysis of LCs. LCs are trained to provide HIV testing and counselling (HTC) and ART adherence support. Funded by international donors, 487 LCs were deployed between 2006 and 2011. However, in 2012, the number of LCs decreased to 165 due to a decreasing donor funds, while administrative and fiscal barriers hampered absorption of LCs into the public health system. That same year, ART coverage decreased from 61% to 51% and facility-based HTC decreased by 15%, from 253 994 in 2011 to 215 042 tests in 2012. The workload analysis indicated that LCs work averagely 77 h per month, bringing considerable relief to the scarce professional health workforce. HIV statistics in Lesotho worsened dramatically in the recent era of reduced support to LCs. This suggests that in order to ensure access to HIV care in an under-resourced setting like Lesotho, a recognized and well-supported counsellor cadre is essential. The continued presence of LCs requires improved prioritization, with national and international support.
Journal Article > ResearchFull Text
Int Health. 2021 March 1; Volume 3 (Issue 1); 66-68.; DOI:10.1016/j.inhe.2010.11.001
van den Akker T, Radge G, Mateyu A, Mwagomba B, Bemelmans M, et al.
Int Health. 2021 March 1; Volume 3 (Issue 1); 66-68.; DOI:10.1016/j.inhe.2010.11.001
Attendance for intrapartum care in Thyolo District, Malawi, was studied following implementation of a locally valued, non-monetary incentive. The number of facility-based deliveries per month was compared between the fourth quarter of 2007 and the third quarter of 2009, before and after introducing the incentive that included soap, a baby blanket and a traditional baby wrap. The number of deliveries in health facilities increased by 78% over the 2-year period. The increase was larger in peripheral rural facilities compared with the district hospital (94% vs. 38%). Locally developed incentives may lead to more women receiving professional maternity care in Malawi, particularly in rural areas.
Journal Article > ResearchAbstract
Trans R Soc Trop Med Hyg. 2010 May 1; Volume 104 (Issue 5); DOI:10.1016/j.trstmh.2010.01.007
Tayler-Smith K, Zachariah R, Massaquoi M, Manzi M, Pasulani O, et al.
Trans R Soc Trop Med Hyg. 2010 May 1; Volume 104 (Issue 5); DOI:10.1016/j.trstmh.2010.01.007
A study conducted among HIV-positive adults in WHO clinical stages 1 and 2 was followed up at Thyolo District Hospital (rural Malawi) to report on: (1) retention and attrition before and while on antiretroviral treatment (ART); and (2) the criteria used for initiating ART. Between June 2008 and January 2009, 1633 adults in WHO stages 1 and 2 were followed up for a total of 282 person-years. Retention in care at 1, 2, 3 and 6 months for those not on ART (n=1078) was 25, 18, 11 and 4% vs. 99, 97, 95 and 90% for patients who started ART (n=555, P=0.001). Attrition rates were 31 times higher among patients not started on ART compared with those started on ART (adjusted hazard ratio, 31.0, 95% CI 22-44). Ninety-two patients in WHO stage 1 or 2 were started on ART without the guidance of a CD4 count, and 11 were incorrectly started on ART with CD4 count > or = 250 cells/mm(3). In a rural district hospital setting in Malawi, attrition of individuals in WHO stages 1 and 2 is unacceptably high, and specific operational strategies need to be considered to retain such patients in the health system.
Journal Article > LetterFull Text
Int J Tuberc Lung Dis. 2012 November 1; Volume 16 (Issue 11); DOI:10.5588/ijtld.12.0466
Biot M, Saranchuk P, Ellman T, Bygrave H, Bemelmans M
Int J Tuberc Lung Dis. 2012 November 1; Volume 16 (Issue 11); DOI:10.5588/ijtld.12.0466