Marielle Bemelmans

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.

Community‐supported models of care for people on HIV treatment in sub‐Saharan Africa

Further scale‐up of antiretroviral therapy (ART) to those in need while supporting the growing patient cohort on ART requires continuous adaptation of healthcare delivery models. We describe several approaches to manage stable patients on ART developed by Médecins Sans Frontières together with Ministries of Health in four countries in sub‐Saharan Africa.

Mortality Reduction Associated with HIV/AIDS Care and Antiretroviral Treatment in Rural Malawi: Evidence from Registers, Coffin Sales and Funerals

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 (X2 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.

Unacceptable attrition among WHO stages 1 and 2 patients in a hospital-based setting in rural Malawi: can we retain such patients within the general health system?

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.

Reduced tuberculosis case notification associated with scaling up antiretroviral treatment in rural Malawi

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 (χ(2) 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 (χ(2) 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.

Getting HIV Treatment to the Most People

Delivering HIV care effectively and ensuring long-term retention of patients requires innovative strategies and tools—and policies that enable their widespread use. The new understanding that antiretroviral therapy (ART) can significantly reduce HIV transmission (1) has stimulated scientific and political leaders to claim that ending the AIDS epidemic is now a realistic goal. At the same time and despite last years major international political commitments to put 15 million people on treatment by 2015 (2), large funding gaps threaten the gains already made and limit the potential to capitalize on the latest scientific progress. Underresourced clinics are managing ever-increasing numbers of people on treatment, even though there is attrition all along the care continuum, from testing to treatment initiation and long-term retention in care (3).

HIV care need not hamper maternity care: a descriptive analysis of integration of services in rural Malawi

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.

Can non-monetary incentives increase health facility deliveries? The experience in Thyolo District, Malawi

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.

The uncertain future of lay counsellors: continuation of HIV services in Lesotho under pressure

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.

Change to patient-centred terminology in tuberculosis: an important step, but what about the treatment strategies?

to review fewer fi elds than recommended before declaring a sputum smear negative, but viewing just four fi elds through the 20× objective will already correspond to the 100 fi elds required by ZN. Examining one full length of a smear corresponds to 500 ZN fi elds, and gives the greatest chance for LED FM to fulfi l its promise of increased sensitivity. As with any technology, poor implementation of LED FM may lead to underperformance. Fortunately, each of these pitfalls—hasty and poor training, overreading of scanty smears with ZN, and the use of 40× or even 100× objectives for screening—can be overcome by using better approaches for training and quality assurance. These may vary from setting to setting and with the experience of the microscopist. To date, we have not seen any published studies measuring LED FM profi ciency after different lengths of training. Such studies are critical to ensure that scaleup of LED FM achieves the goals of reducing laboratory workload and increasing case detection, without increasing false-positive diagnoses.