Bedelu M, et al. Implementing antiretroviral therapy in rural communities: the Lusikisiki model of decentralized HIV/AIDS care. J Infect Dis. 2007 Dec; 196(Suppl 3):S464-S468. No abstract available.
To show that satisfactory outcomes can be achieved when HIV care and treatment is integrated into primary healthcare at the clinic level in a decentralized model in a resource-poor rural setting.
A cohort study of patients receiving antiretroviral treatment (ART) for HIV infection in primary care clinics compared to those treated in the hospital.
Lusikisiki subdistrict, South Africa, one of the poorest and most densely populated areas of South Africa, with high HIV prevalence (31%) and a chronic shortage of physicians and nurses.
The sample included all 595 HIV-infected patients started on ART in the clinics and 430 started on ART in the hospital between January 2004 and June 2005 who completed at least 12 months of treatment by July 2006.
For three years, Médicins Sans Frontières supported a program to deliver HIV care and services in Lusikisiki, South Africa through decentralization to primary healthcare clinics, task shifting within services, training and mentoring of staff, and creating strong community support.
Decentralization and task-shifting: The running of the ART program was delegated to primary healthcare nurses and community health workers. More responsibility was delegated to lower-level health workers, while ensuring that professional medical oversight was provided to maintain quality control.
Training and mentoring through mobile teams: All clinics received regular physician support of overall health services via a mobile team of one MD and one nurse. The mobile teams also provided training and mentoring of nurses in HIV management, PTMCT, management of opportunistic infections, and ART. Training emphasized a high suspicion for TB and the clinical diagnosis of TB in those with negative sputum smears. Systems improvement and quality control were overseen by the mobile team, using a program evaluation tool that looks at specific outcomes of the different components of HIV care on a quarterly basis.
Creating new capacity: The position of adherence counselor was created to help prepare individuals for ART, empower ART recipients, run ART support groups, collect data, mentor community caregivers, and trace individuals who default on their medication. High commitment was maintained by having weekly meetings and workshops to keep adherence counselors engaged. Adherence counselors also undertook all aspects of voluntary counseling and testing, with nurse supervision. The community was engaged in clinic activities through general support groups (for disclosure, testing, and home visits) and ART support groups (which prepared people for treatment and provided support for adherence, managing adverse effects and tracing individuals who have defaulted). A clinic committee represented service users in the case of complaints, advocated for better infrastructure and drug supply, and monitored HIV programs and condom distribution in the community. An adherence committee followed up with non-adherent patients. Individual service users provided important support to other community members by sharing their knowledge and experiences of HIV.
The primary outcomes were adherence, numbers lost to follow-up, CD4 cell count, viral load, and mortality.
HIV-infected persons received treatment faster and had better retention at the clinics than at the hospital. Only 2% of people were lost to follow-up in the clinics, compared with 19% at the hospital. There is no statistical difference between the recorded mortality rates in the hospital and the clinics; however, the percentage of individuals remaining in care was lower in the hospital (67%) than in the clinics (81%). Enrollment initially increased at a similar pace at the clinics and hospital. After 1 year, enrollment at the hospital reached a plateau and then began to decline, suggesting a saturation of services. In contrast, enrollment in the clinics continued to increase. In early 2004, 50% of service users at the hospital and 40% of those at clinics arrived with CD4 cell counts <50 cells/mm3; by the end of 2005, the number of patients with CD4 cell counts <50 cells/ mm3 had decreased to 16% at both the hospital and clinics. Patients were arriving in better health conditions due to the universal coverage achieved in the subdistrict.(1,2) By mid-2006, 22,000 persons were receiving ART, for an estimated 95% coverage of the HIV-infected population. Because people were arriving with a better immune status, clinical management was less time-consuming, which allowed for more patients to be seen
The authors conclude that the greater proximity and acceptability of services at the clinics has led to a faster enrollment of patients into treatment and better retention of patients in treatment. Maintaining quality and coverage will require increased resource input from the public sector and full acceptance of creative approaches to implementation, including task shifting and community involvement.
Based on the Newcastle-Ottawa quality rating for observational cohort studies, this study is of adequate quality. The study had a few limitations. Demographics and baseline clinical indicators of the patients enrolled in the clinics compared to those in the hospital were not given, thus making it difficult to understand whether the two populations were comparable. No information was given on how data were collected and analyzed for this study. The high coverage and improved immune status of patients in the later period of the study appears to be a function of improved HIV screening through counseling and testing, rather than the provision of care by the clinics.
This intervention focused on shifting the system of healthcare from a centralized hospital-based system to a decentralized clinic-based system, where local clinics are equally engaged in primary healthcare and ART administration for patients. Due to a lack of human resources, such a system was developed by creating new positions for trained lay people who were able to engage the community in health discussions and facilitate ease of entry into the health system. Engaging the community in HIV/AIDS care has been proven in previous studies to enhance program quality, in terms of clinical outcomes, adherence rates, and retention.(3) In contrast to what some have suggested, this intervention shows that the provision of ART has had a positive effect on the general quality of primary healthcare.(4) Improvements in drug supply, diagnostic services, monitoring, staff training, and infrastructural improvements all contribute to improving general primary healthcare. Médicins Sans Frontières left Lusikisiki in October 2006. It will be important to observe how well services can be continued without their ongoing support.
This intervention shows the importance of modifying systems and policies in order to accommodate for lack of human resources and capacity at a local subdistrict level. Creating new positions and task shifting to allow nurses and physicians to take on more clinical work resulted in an improved use of scarce human resources. Countries that face similar human resources challenges should consider methods of task shifting, training and mentoring staff, and creating new capacity by hiring lay staff to work closely with patients and engage the community in HIV/AIDS care.
- Medecins Sans Frontieres. Achieving and sustaining universal access to antiretrovirals in rural areas: the primary health care approach to HIV services in Lusikisiki, Eastern Cape. Cape Town, South Africa: Medecins Sans Frontieres, 2006. Accessed 16 August 2007.
- Actuarial Society of South Africa. ASSA 2003 AIDS and demographic model. Accessed 17 August 2007.
- Zachariah R, Teck R, Buhendwa L, et al. How can the community contribute in the fight against HIV/AIDS and tuberculosis? An example from a rural district in Malawi. Trans R Soc Trop Med Hyg 2006; 100:167-75.
- McCoy D, Chopra M, Loewenson R, et al. Expanding access to antiretroviral therapy in sub-Saharan Africa: avoiding the pitfalls and dangers, capitalizing on the opportunities. Am J Public Health 2005; 95: 18-22.