Email updates

Keep up to date with the latest news and content from BMC Health Services Research and BioMed Central.

Open Access Research article

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

Adrienne K Chan12, Deborah Ford3*, Harriet Namata4, Margaret Muzambi5, Misheck J Nkhata1, George Abongomera4, Ivan Mambule6, Annabelle South3, Paul Revill7, Caroline Grundy3, Travor Mabugu5, Levison Chiwaula1, Fabian Cataldo1, James Hakim5, Janet Seeley8, Cissy Kityo4, Andrew Reid5, Elly Katabira6, Sumeet Sodhi1109, Charles F Gilks11, Diana M Gibb3 and the Lablite Team

Author Affiliations

1 Dignitas International, Zomba, Malawi

2 Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Canada

3 MRC Clinical Trials Unit at University College London, London, U.K

4 Joint Clinical Research Centre, Kampala, Uganda

5 University of Zimbabwe, Harare, Zimbabwe

6 Infectious Diseases Institute, Makerere University, Mulago, Uganda

7 Centre for Health Economics, University of York, York, UK

8 MRC/UVRI Uganda Research Unit of AIDS, Entebbe, Uganda

9 Department of Family and Community Medicine, University of Toronto, Toronto, Canada

10 Department of Family and Community Medicine, University Health Network, Toronto Western Hospital, Toronto, Canada

11 School of Population Health, University of Queensland, Queensland, Australia

For all author emails, please log on.

BMC Health Services Research 2014, 14:352  doi:10.1186/1472-6963-14-352

Published: 19 August 2014

Abstract

Background

In 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.

Methods

81 purposively sampled health facilities in Malawi, Uganda and Zimbabwe were surveyed.

Results

The 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.

Conclusions

Although 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.

Keywords:
HIV services; Sub-Saharan Africa; Antiretroviral therapy rollout; Primary care health facilities; Stock-outs; Decentralization