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

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.

Figure 1

Country Maps Demonstrating Geographic Locations of Cross Sectional Survey. A. Locations of Malawi, Uganda and Zimbabwe in sub-Saharan Africa. B. Uganda: Dots indicate 22 districts included in the survey. 13 health facilities from 4 districts in the Central Region, 14 health facilities from 6 districts in the Northern Region, 6 health facilities from 6 districts in the Eastern Region and 6 health facilities from 6 districts in the Western Region were surveyed. Implementation project is taking place in Kalungu (Central Region) and Agago (Northern Region). C. Zimbabwe: 5 health facilities from Zvimba District (site of implementation project), 6 health facilities from Chikomba District, 3 health facilities from Shamva District, 6 health facilities from Makoni District and 2 health facilities in Harare were surveyed. D. Malawi: 3 health facilities from Chitipa (Northern Region), 3 health facilities from Lilongwe (Central Region) and 15 health facilities from Phalombe (Southern Region and site of implementation project) were surveyed.

Figure 2

Laboratory provision in health facilities providing ART on-site. Proportion of facilities with on-site provision or able to refer for testing (remaining facilities have no provision). Referrals may be sample collection on-site with the sample sent to a reference laboratory or the patient may be referred to an alternative facility. A. Haemoglobin. B. White cell count. C. Liver enzymes. D. Urea and creatinine. E. CD4s. F. Viral loads. *Health facilities were asked whether or not they had regular access to CD4 and viral load testing: 1 additional facility in Malawi reported being able to refer for CD4; 3 , 15 and 1 additional facilities in Malawi, Uganda and Zimbabwe respectively reported they could refer for viral load testing but none did so regularly.