Achieving Universal Access to Antiretroviral Therapy in a Rural District in Malawi: How was it done

1
Achieving Universal Access to Antiretroviral
Therapy in a Rural District in Malawi How was
it done ?

• Thyolo District, Malawi
• Authors M. Massaquoi, R. Naligunkwi, U. Von
  Pilar, B. Mwagomba, M. Bemelmans, R. Zachariah,
  A.D. Harries
• Médécins Sans Frontières
• District Health Services- Thyolo, Malawi
• Ministry of health and population- Malawi

2
HIV AND AIDS PROFILE, MALAWI

• Population 12 million
• HIV Infected 1 million
• HIV /AIDS related deaths
  90,000/year
• Needing ART 170,000
• Becoming eligible/year 90,000

Source HIV and Syphilis Sero Survey and
National HIV Prevalence and AIDS Estimates
Report, MOH, 2007
3
The National Goal(Universal Access)
From 2008 on, 45,000 new patients (50 of need)
each year
4
Thyolo district
5
Mulanje Range
6
Achieving Universal ART Access in a rural
districtlike Thyolo, Malawi
Universal access 80 of all people in urgent
need of treatment.

• GOAL FOR Universal Access
• Thyolo district population 600,000
• Global HIV infection rate 10
• People living with HIV/AIDS
  60,000
• Needing ART
  9- 12,000 (15-20)
• Universal access
  7,200 9,600
• MSF targets
• Start 10,000 by Dec. 2007
• And then 5000-7000 new patients each year.

7
METHODS (1)

• Universal Access !
• How did we do it ?
• Key Keep it standardized and simple

8
METHODS (2)

• A public health approach (TB-DOTS model)
• Standard system of case-finding
• Free standard treatment
• Standardized patient monitoring outcomes
• National ART training / supervision /
  accreditation

9
METHODS (3)

• ART Eligibility
• Positive HIV test
• An understanding of the implications of ART
• WHO Clinical Stage III / IV
• CD4 counts lt 250 cells/mm³ when available
• ART Regimen
• One first-line regimen, D4T/3TC/NVP ( FDC)
• Available/Easy to administer/Cheap
• Alternatives D4T EFV

10
METHODS (4)

• Patient flow in HIV Clinic a track system
  (slow/medium/fast) for maximum efficiency.
• Decentralization to health centres
• Task shifting at different levels
• HTC from Nurse ? lay counselors (HSAs / PLWAs)
• ART initiation Clinical Officer ? Medical
  Assistant ? Nurse
• Community involvement
• Opt-Out HIV-testing TB, paediatrics, NRU, wards
• Quarterly Monitoring Paper based system

11
RESULTS (1) HIV- testing1997 2007
Evolution of HIV counseling Testing in Thyolo
District
90000
30
80000
Task shifting Nurses to HSA / PLWAs
25

70000
60000
20
Started increasing testing sites
50000
No. Tested
No. of Sites
15
40000
30000
10
20000
5
10000
0
0
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
No. Tested
No. tested positive
No. of Sites
12
RESULTS (2)
13
RESULTS (3) Universal Access

• Ever started ART 13,702
  (June 2008)
• Retained in care 10, 541 (77)
• Alive and on ART 9,856 (72)
• Transfer out 685 (5)
• Attrition from care 3151 (23)
• Deaths 1480 (11)
• Defaulters 1644 (12)
• Stopped 27 (0.2)
• Universal access target reached August 2007
  (10,273)

14
Thyolo districtComparative analysis Hospital vs
health centres (ART Initiations June 2006-June
2007)
15
RESULTS (5)Probability of attrition Hospital
health centres
Log rank test 0.54, P0.5
16
RESULTS (6)Universal access Costing

• Cost for
• 100 ART patients (2007) 18,569
  Euro
• Consultations
• Essential drugs
• Laboratory
• ARV
• 10, 000 patients (universal access) 1, 856,
  900 Euro
• 3 Euros/inhabitant/year for Thyolo (600,000
  inhabitants) !!
• Excluding coordination costs

17
CURRENT CHALLENGES

• Maintaining universal access
• Human Resources shortages
• Sustaining motivation avoiding burn-out in the
  midst of cumulative cohorts and workload
• Drug supplies / Infrastructure
• Durability of the first-line regimen
• drug resistance and long term side effects
• Access to second-line therapy
• Future funding as about 60 of spending is donor
  driven

18
CONCLUSIONS (1)

• In a rural district of Malawi
• It has been feasible to scale-up ART to achieve
  universal access targets
• Retention rates are high and attrition rates are
  acceptable.

19
CONCLUSIONS (2)

• The key has been
• A simple, structured, standardised approach to
  ART delivery
• Use of task-shifting
• Active involvement of communities
• Good for many instead of best for few

20
THYOLO TEN YEARS 10,000 PATIENTS
21

• ACKNOWLEDGEMENTS
• District Health Services, Thyolo District
• Ministry of Health HIV Unit, Malawi
• Financial support
• Donors
• CIFF Elton John Foundation, ELMA, DGCD,
  EuropAid, Danish Telethon,
• Partners MoH/Global FUND
• Others.