The Lablite project: A cross-sectional mapping survey of decentralized HIV service provision in Malawi, Uganda and Zimbabwe

Abstract

BackgroundIn sub-Saharan Africa antiretroviral therapy (ART) is being decentralized from tertiary/secondary care facilities to primary care. The Lablite project supports effective decentralization in 3 countries. It began with a cross-sectional survey to describe HIV and ART services.Methods81 purposively sampled health facilities in Malawi, Uganda and Zimbabwe were surveyed.ResultsThe lowest level primary health centres comprised 16/20, 21/39 and 16/22 facilities included in Malawi, Uganda and Zimbabwe respectively. In Malawi and Uganda most primary health facilities had at least 1 medical assistant/clinical officer, with average 2.5 and 4 nurses/midwives for median catchment populations of 29,275 and 9,000 respectively. Primary health facilities in Zimbabwe were run by nurses/midwives, with average 6 for a median catchment population of 8,616. All primary health facilities provided HIV testing and counselling, 50/53 (94%) cotrimoxazole preventive therapy (CPT), 52/53 (98%) prevention of mother-to-child transmission of HIV (PMTCT) and 30/53 (57%) ART management (1/30 post ART-initiation follow-up only). All secondary and tertiary-level facilities provided HIV and ART services. In total, 58/81 had ART provision. Stock-outs during the 3 months prior to survey occurred across facility levels for HIV test-kits in 55%, 26% and 9% facilities in Malawi, Uganda and Zimbabwe respectively; for CPT in 58%, 32% and 9% and for PMTCT drugs in 26%, 10% and 0% of facilities (excluding facilities where patients were referred out for either drug). Across all countries, in facilities with ART stored on-site, adult ART stock-outs were reported in 3/44 (7%) facilities compared with 10/43 (23%) facility stock-outs of paediatric ART. Laboratory services at primary health facilities were limited: CD4 was used for ART initiation in 4/9, 5/6 and 13/14 in Malawi, Uganda and Zimbabwe respectively, but frequently only in selected patients. Routine viral load monitoring was not used; 6/58 (10%) facilities with ART provision accessed centralised viral loads for selected patients.ConclusionsAlthough coverage of HIV testing, PMTCT and cotrimoxazole prophylaxis was high in all countries, decentralization of ART services was variable and incomplete. Challenges of staffing and stock management were evident. Laboratory testing for toxicity and treatment effectiveness monitoring was not available in most primary level facilities.Electronic supplementary materialThe online version of this article (doi:10.1186/1472-6963-14-352) contains supplementary material, which is available to authorized users.

On the front line of HIV virological monitoring: barriers and facilitators from a provider perspective in resource-limited settings

“…Task-shifting helped distribute the burden of VL monitoring activities, particularly specimen collection, (Callaghan, Ford, & Schneider, 2010; Chan et al, 2014; Pannus et al, 2014) and facilitated access to VL monitoring in more remote clinics and health centers where nurses and clinicians may not rotate regularly.…”

Impact of decentralisation of antiretroviral therapy services on HIV testing and care at a population level in Agago District in rural Northern Uganda: results from the Lablite population surveys

“…23 Although numbers were small, the majority of the children in care attended Kalongo Hospital for ART, and some carers cited fear of drug stock-outs as the reason for not accessing ART locally; previous work has suggested that stockouts of paediatric ART may be more frequent than of adult ART. 24 Post-decentralisation, over two-thirds of the population reported the local primary care facility as the nearest facility where one could receive ART, although fewer participants were aware of local ART availability in the villages furthest from the health facility, suggesting community engagement could still be improved.…”

Determinants of durability of first-line antiretroviral therapy regimen and time from first-line failure to second-line antiretroviral therapy initiation

“…The supply chain of paediatric regimens is particularly vulnerable to breakdown because of storage requirements. In a survey of decentralized HIV service provision in Malawi, Uganda and Zimbabwe, 24% of clinics experienced stockouts of paediatric ART, whereas only 7% experienced stock outs of adult ART [18]. These findings underline one of many operational difficulties in sustainable roll-out of paediatric ART.…”