versão impressa ISSN 0042-9686
Bull World Health Organ vol.88 no.10 Genebra Out. 2010
LESSONS FROM THE FIELD
Élargissement de l'accès au traitement antirétroviral au niveau des centres de santé ruraux grâce à un service mobile dans le district de Mumbwa, Zambie
Expansión del tratamiento antirretroviral a nivel de los centros de salud rurales mediante un servicio móvil en el distrito de Mumbwa, Zambia
Christopher DubeI; Ikuma NozakiII,*; Tadao HayakawaIII; Kazuhiro KakimotoII; Norio YamadaIV; James B SimpungweV
IMumbwa District Health Office, Mumbwa, Zambia
IIInternational Medical Center of Japan, 1-21-1 Toyama, Shinjuku, Tokyo, Japan
IIIJapan International Cooperation Agency, Tokyo, Japan
IVResearch Institute of Tuberculosis, Tokyo, Japan
VClinical Care and Diagnostics Services, Ministry of Health, Lusaka, Zambia
PROBLEM: Despite the Government's effort to expand services to district level, it is still hard for people living with HIV to access antiretroviral treatment (ART) in rural Zambia. Strong demands for expanding ART services at the rural health centre level face challenges of resource shortages.
APPROACH: The Mumbwa district health management team introduced mobile ART services using human resources and technical support from district hospitals, and community involvement at four rural health centres in the first quarter of 2007. This paper discusses the uptake of the mobile ART services in rural Mumbwa.
LOCAL SETTING: Mumbwa is a rural district with an area of 23 000 km2 and a population of 167 000. Before the introduction of mobile services, ART services were provided only at Mumbwa District Hospital.
RELEVANT CHANGES: The mobile services improved accessibility to ART, especially for clients in better functional status, i.e. still able to work. In addition, these mobile services may reduce the number of cases "lost to follow-up". This might be due to the closer involvement of the community and the better support offered by these services to rural clients.
LESSONS LEARNT: These mobile ART services helped expand services to rural health facilities where resources are limited, bringing them as close as possible to where clients live.
PROBLÈME: Malgré les efforts du gouvernement en matière de développement de l'accès aux services au niveau du district, il s'avère encore très difficile pour les personnes atteintes du VIH de bénéficier du traitement antirétroviral (TAR) en Zambie rurale. Les appels soutenus pour le développement de services d'accès au TAR au niveau des centres de santé ruraux doivent faire face à une pénurie de ressources.
APPROCHE: L'équipe de direction médicale du district de Mumbwa a mis en place les services mobiles de TAR, en utilisant les ressources humaines et le soutien technique des hôpitaux du district, ainsi qu'un engagement communautaire dans quatre centres de santé ruraux au cours du premier trimestre de l'année 2007. Cet article va traiter du succès des services mobiles de TAR dans le district rural de Mumbwa.
ENVIRONNEMENT LOCAL: Mumbwa est un district rural d'une superficie de 23 000 km2 et de 167 000 habitants. Avant l'introduction des services mobiles, les services de TAR étaient uniquement accessibles à l'hôpital du district de Mumbwa (Mumbwa District Hospital).
CHANGEMENT SIGNIFICATIFS: Les services mobiles ont amélioré l'accessibilité au TAR, notamment pour les patients dans un meilleur état de santé, c'est-à-dire ceux qui peuvent encore travailler. De plus, ces services mobiles pourraient réduire le nombre de cas «perdus au suivi». Cela pourrait être la conséquence d'une participation plus importante de la communauté et d'un soutien amélioré de ces services aux patients ruraux.
LEÇONS TIRÉES: Ces services mobiles de TAR ont aidé à développer les services aux centres de santé ruraux où les ressources sont limitées, les rapprochant le plus possible de leurs patients.
SITUACIÓN: A pesar de los esfuerzos del Gobierno por extender los servicios hasta el nivel de distrito, sigue resultando difícil que las personas con VIH accedan al tratamiento antirretroviral (TAR) en la Zambia rural. Las enérgicas súplicas para ampliar los servicios relacionados con el TAR a los centros de salud rurales se enfrentan a las dificultades derivadas de la escasez de recursos.
ENFOQUE: El equipo de gestión sanitaria en el distrito de Mumbwa introdujo servicios móviles de TAR que hacían uso de recursos humanos y asesoramiento técnico de hospitales de distrito, así como la participación de la comunidad en cuatro centros de salud rurales en el primer trimestre de 2007. Este trabajo aborda el uso de los servicios móviles de TAR en el distrito rural de Mumbwa.
MARCO REGIONAL: Mumbwa es un distrito rural con un área de 23 000 km2 y una población de 167 000 habitantes. Antes de la introducción de los servicios móviles, los servicios de TAR se proporcionaban sólo en el Hospital de Distrito de Mumbwa.
CAMBIOS IMPORTANTES: Los servicios móviles mejoraron la accesibilidad al TAR, especialmente para usuarios con un mejor estado funcional, es decir, aún capaces de trabajar. Además, estos servicios móviles pueden reducir el número de casos de «pérdidas durante el seguimiento». Esto podría deberse a la mayor implicación de la comunidad y al mejor apoyo ofrecido por estos servicios a los usuarios en las áreas rurales.
LECCIONES APRENDIDAS: Estos servicios móviles para el TAR ayudaron a extender los servicios a los centros de salud rurales cuando los recursos fueron limitados, acercándolos lo máximo posible a los lugares donde viven los usuarios.
Zambia is one of the sub-Saharan African countries worst affected by the HIV pandemic. In 2007, the prevalence rate among adults was approximately 14.3% and there were an estimated 1.5 million HIV-infected people.1,2 In 2004, the government of Zambia declared HIV/AIDS a national crisis and launched a policy of free antiretroviral treatment (ART), that made free ART available in 322 sites.2,3
However, more than half of the population lives in rural areas where there is poor access to ART services.1 Several studies reported that long travel distances are a potential barrier to accessing services and, after starting ART, they are a barrier to optimal adherence.4-6 To improve accessibility, ART services need to be located as close to the community as possible. Thus, Mumbwa district health management team introduced a mobile ART service at rural health centres as a pilot programme of the Ministry of Health. This paper discusses the uptake of these mobile services in rural Mumbwa.
Mumbwa District is one of 72 districts in Zambia, with an area of 23 000 km2 and a population of 167 000. There are 28 public health facilities including a district hospital, as well as a mission hospital and private facilities. Health-care providers in the whole district consist of five medical doctors, 24 clinical officers, 44 nurses and 33 midwives. The district hospital plays a role as a referral hospital for care, support and treatment of HIV. It is equipped with an X-ray machine, a blood cell counter, a biochemistry analyzer, a CD4+ lymphocyte (CD4) counter, a microscopic examination and urinalysis. Rural health centres are usually staffed by only two to four medical professionals such as clinical officers, nurses and/or an environmental health technician. They offer simple examinations such as rapid tests while X-ray examination and most laboratory services including haemoglobin are only available in hospitals.
In 2006, ART services were provided only at Mumbwa District Hospital. The number of clients receiving ART was less than 450 in April 2006, although the number of clients in need of ART was estimated approximately 5000 to 7500.
Mobile ART services commenced at four rural health centres in the first quarter of 2007. Before the implementation of the services, staff members at the four sites attended a 10-day training course in management of ART and optimistic infection conducted by the experienced staff of the district health management team and Mumbwa District Hospital. Lay counsellors and support group members, of whom most are HIV-positive and on ART, were selected from the community and trained in HIV prevention, ART and counselling skills to assist staff members in the rural health centres. Almost daily, lay counsellors gave psychosocial counselling to ART patients in the community, and support group members reminded them of the arrival of the mobile service. Rural health centres were selected as mobile ART sites according to geographical location, coverage population and existing resources including medical staff, space and community activities. A mobile ART team including a medical doctor, clinical officer, nurse, laboratory staff and pharmacist visited the ART sites every two weeks.
Eligibility for the mobile ART services was assessed by either CD4 cell count (for which blood samples were sent to the district hospital laboratory) or clinical symptoms. Eligible patients were monitored in the same manner as the hospital by trained professionals either from the mobile team or ones from the rural health centre depending on staff availability in the health centre. However, complicated cases that could not be treated by the mobile service were transferred to the hospital.
Operational cost for the four mobile ART services expended by the district health management team, which was the only source of funding, was 86 million kwacha per year (approximately 17 000 United States dollars) which included allowances for team members, fuel and motor vehicle services.
Except for those aged less than18 years, client data were collected from the ART registration books at the district hospital and the rural health centres. All clients who were newly enrolled for ART in 2007 were included in the analysis (232 cases in the mobile sites and 458 cases in the district hospital). Conditions of the clients at the 6th month after starting treatment were categorized as "retained at original site", "lost to follow-up", "dead" and "transfer out" as treatment outcomes.
The accumulated number of ART clients from both mobile sites and the district hospital reached 2053 in the second quarter of 2008, accounting for 25% to 40% of the estimated clients in need of ART in the district (Fig. 1). Of those who were newly enrolled up to the second quarter of 2008, 46.6% (578/1295) initiated ART using the mobile services.
Average age of ART clients included in the analysis was 38.1 years (standard deviation 10.09) and 60.3% of them were female. There were no differences in the pattern of age and gender of patients attending the district hospital and the rural health centres. However, clients presented at the rural health centres at an earlier stage and with better functional status than those presenting at the district hospital.
Table 1 shows that the percentage of patients "lost to follow up" in the mobile ART sites was lower than at the district hospital. A greater percentage of rural health centre patients died during the study period.
The mobile service increased the number of ART clients in the district probably because it reduced the long distances required to travel to health services in rural areas. This allowed clients to start ART at an earlier stage. Mobile ART services might have encouraged people to seek voluntary counselling and testing before showing symptoms (Box 1).
There were less transfers and "lost to follow up" patients at the mobile sites during the first six months of treatment. Effective community involvement in rural health centres may have made it easier to educate clients and to prevent loss to follow up. In addition, lay counsellors and community support groups contributed to relieving the shortage of human resources. Retention rates at the first six months of treatment in other studies in African countries vary from 39.2% to 86.7%.7 These compare well with the 69.5-75.9% retention rates we observed in this study.
In contrast, the mortality of patients at mobile sites at the first six months was higher than during the same period at the district hospital. This may be due to misclassification of deaths recorded as "lost to follow-up" at the district hospital.
Other studies have estimated that about 75% of the deaths that occur in the first three months of treatment are due to immune reconstitution inflammatory syndrome.8 However, clients using mobile ART sites at an earlier stage of their disease do not incur the same risk of immune reconstitution inflammatory syndrome.
This study has some limitations. First, the comparison between mobile ART sites and the district hospital was made in the same period. Clients in the hospital enrolled since the introduction of mobile ART to the rural health centres might have different social demographic characters from the ones enrolled before mobile services were made available. This analysis is, however, important because the resources such as infrastructure, equipment and human resources in the hospital are very different from the rural health centres. Second, details of the treatment outcomes, case management and co-morbidities were not provided. Since the study was done in non-research settings, comparisons such as using CD4 cell counts could not be done.
Mobile ART services involving lay counsellors and support groups seemed to be a beneficial and effective strategy to improve accessibility at health facilities without standardized equipment and human resources. More importantly, other barriers such as stigma and discrimination must be cleared. To our knowledge, this is the first comparison of mobile ART services involving community resources in rural areas with hospital-based services. Further investigation is required to evaluate long-term outcomes including clinical status, adherence and quality of life.
Funding: Japan International Cooperation Agency
Competing interests: None declared.
1. Zambia Demographic and Health Survey 2007, preliminary report. Luska: Central Statistics Office; 2008. [ Links ]
2. Report ZC. Multi-sectoral AIDS Response Monitoring and Evaluation Biennial Report [submitted to the United Nations General Assembly Special Session on AIDS 2006-2007]. Lusaka: National AIDS Council/Ministry of Health; 2008. [ Links ]
3. The mid-term review report of the National Health Strategic Plan 2001-2005. Lusaka: Ministry of Health; 2005. Available from: http://www.moh.gov.zm/?q=node/publications [accessed 24 August 2010] [ Links ].
4. Grace CJ, Soons KR, Kutzko D, Alston WK, Ramundo M. Service delivery for patients with HIV in a rural state: the Vermont model. AIDS Patient Care STDS 1999;13:659-66. doi:10.1089/apc.1999.13.659 PMID:10743511 [ Links ]
5. Reif S, Golin CE, Smith SR. Barriers to accessing HIV/AIDS care in North Carolina: rural and urban differences. AIDS Care 2005;17:558-65. PMID:16036242 [ Links ]
6. Stout BD, Leon MP, Niccolai LM. Nonadherence to antiretroviral therapy in HIV-positive patients in Costa Rica. AIDS Patient Care STDS 2004;18:297- 304. doi:10.1089/108729104323076034 PMID:15186713 [ Links ]
7. Sydney R, Matthew PF, Christopher JG. Patient retention in antiretroviral therapy programs in sub-Saharan Africa: a systematic review. PLoS Med 2007;4:1691-701. [ Links ]
8. Murdoch DM, Venter WDF, Feldman C, Van Rie A. Incidence and risk factors for the immune reconstitution inflammatory syndrome in HIV patients in South Africa: a prospective study. AIDS 2008;22:601-10. doi:10.1097/ QAD.0b013e3282f4a607 PMID:18317001 [ Links ]
(Submitted: 9 February 2009 - Revised version received: 14 January 2010 - Accepted: 24 February 2010 - Published online: 3 September 2010 )