Expanding antiretroviral therapy in Malawi: drawing on the country's experience with tuberculosis

Harries, Anthony; Libamba, Edwin; Schouten, Erik J; Mwansambo, Andrina; Salaniponi, F. M. L.; Mpazanje, Rex

doi:10.1136/bmj.329.7475.1163

Cited by 42 publications

(34 citation statements)

References 7 publications

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“…11 The incentives were only given to those who elected to participate in the testing. Therefore, using the incentive amounts as instruments for those individuals requires an added assumption that the decision to participate in the testing is uncorrelated with v it−1 .…”

Section: Empirical Frameworkmentioning

confidence: 99%

How Beliefs About HIV Status Affect Risky Behaviors: Evidence from Malawi

2009

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Many HIV testing programs in Africa and elsewhere aim to reduce risk-taking behaviors by providing individuals with information about their own HIV status. This paper examines how beliefs about own HIV status affect risky sexual behavior using data from married couples living in three regions of Malawi. Risky behavior is measured as the propensity to engage in extramarital affairs or to not use condoms. The empirical analysis is based on two panel surveys for years 2004 and 2006 from the Malawi Diffusion and Ideational Change Project (MDICP) and from an experimental HIV testing intervention carried out in 2004 that provided randomized incentives for picking up test results. Most individuals participating in the MDICP testing learned that they were HIV negative and a small fraction that they were positive. Controlling for potential endogeneity between beliefs and risk-taking, we find that downward revisions in the subjective belief of being HIV positive lead to decreases in the propensity to engage in extra-marital affairs but have no effect on condom use. These results are generally supported by survey questions that directly elicited from respondents how participating in testing altered their behavior. We show that the estimates provide a lower bound in the presence of measurement error in extra-marital affairs. Most individuals participating in the MDICP testing learned that they were HIV negative and a small fraction that they were positive. Controlling for potential endogeneity between beliefs and risk-taking, we find that downward revisions in the subjective belief of being HIV positive lead to decreases in the propensity to engage in extra-marital affairs but have no effect on condom use. These results are generally supported by survey questions that directly elicited from respondents how participating in testing altered their behavior. We show that the estimates provide a lower bound in the presence of measurement error in extra-marital affairs.

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Section: Empirical Frameworkmentioning

confidence: 99%

How Beliefs About HIV Status Affect Risky Behaviors: Evidence from Malawi

2009

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“…Malawi has developed its own stanm m dardized treatment outcomes for assessm m ing the effectiveness of antiretroviral therapy, [3][4][5] although these are in line with those developed by WHO. 7 What may be unique to Malawi is the empham m sis on quarterly and cumulative cohort analyses.…”

Section: Collection and Interpretation Of Routine Datamentioning

confidence: 99%

“…4,5 In brief, the tools for monitoring antiretroviral therapy include the patient master card (the front of the card is used for case registration and monthly outcomes and the back is used for the indicator diseases by which the patient is staged for therapy), the register of patients (where the leftmhand page is used for case registration and the adjacent page for outcome data), and the quarterly and cumulative cohort analysis forms. The cards, registers and forms are kept in the clinic; the patients' cards and cohort analysis forms are filed in sequence within polypropylene sheet protectors.…”

Section: Registering and Monitoring Patientsmentioning

confidence: 99%

“…Standardized treatment outm m comes are recorded, as well as ambulatory status, work status, side effects of drugs and pill counts (to determine whether patients are taking the drugs correctly). 4,5 At the start of every new quarter, pam m tients' master cards are inspected, and the data from the last month of the previous quarter are used to update the patient register. Once the register is updated, its data are used to conduct quarterly and cumulative cohort analyses.…”

Section: Registering and Monitoring Patientsmentioning

confidence: 99%

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Supervision, monitoring and evaluation of nationwide scale-up of antiretroviral therapy in Malawi

Libamba

Makombe

Mhango

et al. 2006

Bull World Health Organ

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Objective To describe the supervision, monitoring and evaluation strategies used to assess the delivery of antiretroviral therapy during nationwide scale-up of treatment in Malawi. Methods In the first quarter of 2005, the HIV Unit of the Ministry of Health and its partners (the Lighthouse Clinic; Médecins Sans Frontières-Belgium, Thyolo district; and WHO's Country Office) undertook structured supervision and monitoring of all public sector health facilities in Malawi delivering antiretroviral therapy. Findings Data monitoring showed that by the end of 2004, there were 13 183 patients (5274 (40%) male, 12 527 (95%) adults) who had ever started antiretroviral therapy. Of patients who had ever started, 82% (10 761/13 183) were alive and taking antiretrovirals; 8% (1026/13 183) were dead; 8% (1039/13 183) had been lost to follow up; < 1% (106/13 183) had stopped treatment; and 2% (251/13 183) had transferred to another facility. Of those alive and on antiretrovirals, 98% (7098/7258) were ambulatory; 85% (6174/7258) were fit to work; 10% (456/4687) had significant side effects; and, based on pill counts, 96% (6824/7114) had taken their treatment correctly. Mistakes in the registration and monitoring of patients were identified and corrected. Drug stocks were checked, and one potential drug stock-out was averted. As a result of the supervisory visits, by the end of March 2005 recruitment of patients to facilities scheduled to start delivering antiretroviral therapy had increased. Conclusion This report demonstrates the importance of early supervision for sites that are starting to deliver antiretroviral therapy, and it shows the value of combining data collection with supervision. Making regular supervisory and monitoring visits to delivery sites are essential for tracking the national scale-up of delivery of antiretrovirals.Keywords HIV infections/drug therapy; Acquired immunodeficiency syndrome/drug therapy; Anti-retroviral agents; National health programs/organization and administration; Program evaluation; Malawi (source: MeSH, NLM). Voir page 325 le résumé en français. En la página 325 figura un resumen en español. Mots clés

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“…8,9 Lessons from the field Ensuring uninterrupted antiretroviral therapy in resource-poor settings Anthony D Harries et al Alternative first-line regimens are offered in case of side-effects and/or specific contraindications, and a second-line regimen in case of treatment failure. Because of limited experience in estimating demand for, and in the use of, these drugs, orders are made only for central hospitals and two large district hospitals.…”

Section: Key Principles Of Art Procurement and Delivery In Malawimentioning

confidence: 99%

Ensuring uninterrupted supplies of antiretroviral drugs in resource-poor settings: an example from Malawi

Harries

Schouten

Makombe

et al. 2007

Bull World Health Organ

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Problem Drug procurement and distribution practices are weak in many resource-poor countries, and are a major reason for lack of access to medicines. With many countries scaling up antiretroviral therapy (ART), it is vital to avoid interrupted drug supplies, which would lead to drug resistance and treatment failure. Approach Malawi has adapted a model, based on that adopted by the country's Tuberculosis Control Programme, to allow rational ART drug forecasting. Local setting The model includes a focus on one standardized first-line ART regimen; a "push system" and "ceilings" for first-line ART drugs for facilities; use of starter pack and continuation pack kits; quarterly monitoring of patient outcomes and ART drug stocks at facility level; provision of a three-month buffer stock of ART drugs at facility level; and use of a procurement and distribution system outside central medical stores. Lessons learned The focus on a single first-line regimen, "ceilings" for first-line ART drugs and quarterly data collections to calculate drug needs (for new and follow-up patients, respectively), as well as the use of an independent procurement facility, allow drug orders to be made 6-9 months ahead. These measures have so far ensured that there have been no ART drug stock-outs in the country. Une traduction en français de ce résumé figure à la fin de l'article. Al final del artículo se facilita una traducción al español.

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Expanding antiretroviral therapy in Malawi: drawing on the country's experience with tuberculosis

Cited by 42 publications

References 7 publications

How Beliefs About HIV Status Affect Risky Behaviors: Evidence from Malawi

How Beliefs About HIV Status Affect Risky Behaviors: Evidence from Malawi

Supervision, monitoring and evaluation of nationwide scale-up of antiretroviral therapy in Malawi

Ensuring uninterrupted supplies of antiretroviral drugs in resource-poor settings: an example from Malawi

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