Impact and economic evaluation of a novel HIV service delivery model in rural Malawi

McBain, Ryan; Petersen, Elizabeth M.; Tophof, Nora; Dunbar, Elizabeth L; Kalanga, Noel; Nazimera, Lawrence; Mganga, Andrew; Dullie, Luckson; Mukherjee, Joia S.; Wroe, Emily

doi:10.1097/qad.0000000000001578

Cited by 18 publications

(23 citation statements)

References 23 publications

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“…One of the most significant constraints is financing to support this model, as Malawi is one of the poorest countries in the world. 7 We have published elsewhere on the cost-effectiveness of this model, 45 showing that a quality-adjusted life year gained—on average—from the model costs less than three times the GDP per capita, a traditional marker of cost-effectiveness. 46 Beyond cost considerations are additional questions of scalability.…”

Section: Discussionmentioning

confidence: 99%

Delivering comprehensive HIV services across the HIV care continuum: a comparative analysis of survival and progress towards 90-90-90 in rural Malawi

Wroe¹,

Dunbar²,

Kalanga³

et al. 2018

BMJ Glob Health

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IntroductionPartners In Health and the Malawi Ministry of Health collaborate on comprehensive HIV services in Neno, Malawi, featuring community health workers, interventions addressing social determinants of health and health systems strengthening. We conducted an observational study to describe the HIV care continuum in Neno and to compare facility-level HIV outcomes against health facilities nationally.MethodsWe compared facility-level outcomes in Neno (n=13) with all other districts (n=682) from 2013 to 2015 using mixed-effects linear regression modelling. We selected four outcomes that are practically useful and roughly mapped on to the 90-90-90 targets: facility-based HIV screenings relative to population, new antiretroviral therapy (ART)enrolments relative to population, 1-year survival rates and per cent retained in care at 1 year.ResultsIn 2013, the average number of HIV tests performed, as a per cent of the adult population, was 11.75%, while the average newly enrolled patients was 10.03%. Percent receiving testing increased by 4.23% over 3 years (P<0.001, 95% CI 2.98% to 5.49%), while percent enrolled did not change (P=0.28). These results did not differ between Neno and other districts (P=0.52), despite Neno having a higher proportion of expected patients enrolled. In 2013, the average ART 1-year survival was 80.41% nationally and 91.51% in Neno, which is 11.10% higher (P=0.002, 95% CI 4.13% to 18.07%). One-year survival declined by 1.75% from 2013 to 2015 (P<0.001, 95% CI −2.61% to −0.89%); this was similar in Neno (P=0.83). Facility-level 1-year retention was 85.43% nationally in 2013 (P<0.001, 95% CI 84.2% to 86.62%) and 12.07% higher at 97.50% in Neno (P=0.001, 95% CI 5.08% to19.05%). Retention declined by 2.92% (P<0.001, 95% CI −3.69% to −2.14%) between 2013 and 2015, both nationally and in Neno.ConclusionThe Neno HIV programme demonstrated significantly higher survival and retention rates compared with all other districts in Malawi. Incorporating community health workers, strengthening health systems and addressing social determinants of health within the HIV programme may help Malawi and other countries accelerate progress towards 90-90-90.

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Section: Discussionmentioning

confidence: 99%

Delivering comprehensive HIV services across the HIV care continuum: a comparative analysis of survival and progress towards 90-90-90 in rural Malawi

Wroe¹,

Dunbar²,

Kalanga³

et al. 2018

BMJ Glob Health

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“…Prior to 2015, home visits by CHWs were used to improve utilisation of HIV, tuberculosis, Kaposi Sarcoma and palliative care services in Neno District, Malawi [13][14][15]. In 2015, Neno had the best HIV outcomes in Malawi, with the success partially attributed to the CHW program [14]. Based on gaps within other CHW programs in Malawi and our prior experience in Neno in HIV, tuberculosis, Kaposi Sarcoma and palliative care services, we hypothesised that a CHW program may increase utilisation of perinatal services.…”

Section: Introductionmentioning

confidence: 99%

Increasing utilisation of perinatal services: estimating the impact of community health worker program in Neno, Malawi

Kachimanga

Dunbar²,

Watson

et al. 2020

BMC Pregnancy Childbirth

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Background: By 2015, Malawi had not achieved Millennium Development Goal 4, reducing maternal mortality by about 35% from 675 to 439 deaths per 100,000 livebirths. Hypothesised reasons included low uptake of antenatal care (ANC), intrapartum care, and postnatal care. Involving community health workers (CHWs) in identification of pregnant women and linking them to perinatal services is a key strategy to reinforce uptake of perinatal care in Neno, Malawi. We evaluated changes in uptake after deployment of CHWs between March 2014 and June 2016. Methods: A CHW intervention was implemented in Neno District, Malawi in a designated catchment area of about 3100 women of childbearing age. The pre-intervention period was March 2014 to February 2015, and the postintervention period was March 2015 to June 2016. A 5-day maternal health training package was delivered to 211 paid and supervised CHWs. CHWs were deployed to identify pregnant women and escort them to perinatal care visits. A synthetic control method, in which a "counterfactual site" was created from six available control facilities in Neno District, was used to evaluate the intervention. Outcomes of interest included uptake of first-time ANC, ANC within the first trimester, four or more ANC visits, intrapartum care, and postnatal care follow-up. Results: Women enrolled in ANC increased by 18% (95% Credible Interval (CrI): 8, 29%) from an average of 83 to 98 per month, the proportion of pregnant women starting ANC in the first trimester increased by 200% (95% CrI: 162, 234%) from 10 to 29% per month, the proportion of women completing four or more ANC visits increased by 37% (95% CrI: 31, 43%) from 28 to 39%, and monthly utilisation of intrapartum care increased by 20% (95% CrI: 13, 28%) from 85 to 102 women per month. There was little evidence that the CHW intervention changed utilisation of postnatal care (− 37, 95% CrI: − 224, 170%). Conclusions: In a rural district in Malawi, uptake of ANC and intrapartum care increased considerably following an intervention using CHWs to identify pregnant women and link them to care.

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“…Neno has achieved some of the strongest HIV outcomes in Malawi, with 12-month survival rates over 10% points higher than the national average. 3 The Neno Chronic Care Clinic was established in 2009 at the district hospital to provide ongoing management of non-communicable diseases (NCDs) including hypertension, asthma, epilepsy, diabetes and congestive heart failure. The Chronic Care Clinic expanded to the Lisungwi Community Hospital in 2013 (see figure 1 for a map of health facilities in Neno district).…”

Section: Introductionmentioning

confidence: 99%

“…The decentralisation of IC 3 , along with recognition of the role CHWs played in the strong HIV outcomes in Neno district, 3 provided an opportunity to expand the role of CHWs to focus on the health of entire households rather than the previous focus only on patients already diagnosed with HIV and TB. In the existing model, starting in 2007, CHWs were paired with an average of six HIV and/or TB clients to monitor medication adherence and side effects and accompany clients to clinical visits.…”

Section: Introductionmentioning

confidence: 99%

Evaluating the impact of a community health worker programme on non-communicable disease, malnutrition, tuberculosis, family planning and antenatal care in Neno, Malawi: protocol for a stepped-wedge, cluster randomised controlled trial

et al. 2018

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IntroductionThis protocol concerns the implementation and evaluation of an intervention designed to realign the existing cadre of community health workers (CHWs) in Neno district, Malawi to better support the care needs of the clients they serve. The proposed intervention is a ‘Household Model’ where CHWs will be reassigned to households, rather than to specific patients with HIV and/or tuberculosis (TB).Methods and analysisUsing a stepped-wedge, cluster-randomised design, this study investigates whether high HIV retention rates can be replicated for non-communicable diseases (NCDs), and the model’s impact on TB and paediatric malnutrition case finding, as well as the uptake of family planning and antenatal care. Eleven sites (health centres and hospitals) were arranged into six clusters (average cluster population 21 800). Primary outcomes include retention in care for HIV and chronic NCDs, TB case finding, paediatric malnutrition case finding, and utilisation of early and complete antenatal care. Clinical outcomes are based on routinely collected data from the Ministry of Health’s District Health Information System 2 and an OpenMRS electronic medical record supported by Partners In Health. Additionally, semistructured qualitative interviews with various stakeholders will assess community perceptions and context of the Household Model.Ethics and disseminationEthics approval has been obtained from the Malawian National Health Science Research Committee (#16/11/1694) in Lilongwe, Malawi; Partners Healthcare Human Research Committee (#2017P000548/PHS) in Somerville, Massachusetts; and the Biomedical and Scientific Research Ethics Sub-Committee (REGO-2017–2060) at the University of Warwick in Coventry, UK. Dissemination will include manuscripts for peer-reviewed publication as well as a full report detailing the findings of the intervention for the Malawian Ministry of Health.Trial registration numberNCT03106727.Primary sponsorPartners In Health | Abwenzi Pa Za Umoyo P.O. Box 56, Neno, Malawi. Protocol Version 4, March 2018.

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Impact and economic evaluation of a novel HIV service delivery model in rural Malawi

Cited by 18 publications

References 23 publications

Delivering comprehensive HIV services across the HIV care continuum: a comparative analysis of survival and progress towards 90-90-90 in rural Malawi

Delivering comprehensive HIV services across the HIV care continuum: a comparative analysis of survival and progress towards 90-90-90 in rural Malawi

Increasing utilisation of perinatal services: estimating the impact of community health worker program in Neno, Malawi

Evaluating the impact of a community health worker programme on non-communicable disease, malnutrition, tuberculosis, family planning and antenatal care in Neno, Malawi: protocol for a stepped-wedge, cluster randomised controlled trial

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