Optimising clinical care strategies and laboratory monitoring for cost-effective roll-out of antiretroviral therapy in Africa: the Lablite project
How can HIV clinical care strategies and laboratory monitoring be optimised for cost-effective roll-out of Antiretroviral Therapy in Africa?
What was this study about?
Following on from the results of the DART trial this project aims to demonstrate, outside the context of a clinical trial, how treatment for HIV can be decentralised to lower-level health care centres in sub-Saharan Africa. The aim is to show that it is possible to increase coverage and access to treatment in a cost-effective manner in Uganda, Malawi and Zimbabwe. The project has 3 overall aims:
- To map and describe delivery of training and clinical care , use of laboratories and treatment monitoring in HIV treatment centres through a survey of representative sites
- To demonstrate how decentralised strategies of clinical care and use of laboratories, informed by results from DART, would work in basically equipped health centres away from major hospitals
- To assess the economic consequences of different ART delivery strategies– in particular the cost-effectiveness, budget impact, equity effects and health system implications of the delivery strategies for ART roll-out in Africa.
A cross-cutting area of work will be in communicating to influence policy.
Two population-based surveys were conducted in Northern Uganda to assess the impact of decentralisation of ART on uptake of HIV-testing, ART coverage and access to ART.
What difference did this study make?
Lablite supported 9 lower-level clinics in Malawi, Uganda and Zimbabwe to gain national ART accreditation to initiate and follow-up patients on ART. These clinics initiated ~3,200 HIV patients on ART during Lablite, with substantial numbers of additional patients benefitting from transferring into local care. This will continue beyond the end of Lablite. As well as this, Lablite have supported 6 clinics who were already delivering ART before the start of Lablite, developing their capacity to deliver ART and provide mentoring and support to spoke sites. The hub sites have initiated ~7,700 new patients on ART during Lablite and continued to care for patients on ART pre-Lablite, and act as referral facilities for complex cases from the spokes and other lower-level facilities.
A representative from the Uganda Ministry of Health reported that Lablite have helped to build confidence that capacity can be built at spoke sites to deliver ART. Some of the training resources developed by Lablite have been adopted into practice at district and national level.
Decentralisation of ART to spoke facilities has already had an impact on patients. As the equity research has found, patients who are accessing ART at spoke clinics now benefit from a reduction in travel time and /or cost, compared to those accessing ART at hubs. The qualitative research has also revealed positive impacts for patients, with reduced queuing times in central health facilities.In Zimbabwe Lablite captured data before and after roll-out of Option B+ (ART for all pregnant and breastfeeding women); women starting ART during pregnancy and breastfeeding were shown to more likely to disengage from care than other adults, suggesting more support is needed for this group.
The Ugandan population surveys demonstrated increases in HIV-testing and ART coverage following decentralisation of ART; although some patients were reluctant to transfer out of district hospitals to local care.
Type of study
Who funded the study?
UK Department for International Development.
When did it take place?
The project ran from 01 May 2011 to 30 April 2014.
Where did it take place?
Project Partners: • Joint Clinical Research Centre, Kampala, Uganda • MRC / Uganda Virus Research Institute, Entebbe, Uganda • Dignitas International, Zomba, Malawi • University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe • MRC Clinical Trials Unit, London, UK • Imperial College, London, UK • Centre for Health Economics, University of York, UK
Who was included?
This is not a clinical trial – it is a project taking the results of a clinical trial and demonstrating they can be implemented, whilst subjecting them to rigorous evaluation and economic scrutiny. As such there will be no ‘recruitment’ to the trial. The demonstration sites will consist of 4 ‘hub and spoke’ referral systems (2 in Uganda, 1 each in Malawi and Zimbabwe) for HIV-infected adults and children. The ‘hub’ is a larger, better equipped, probably urban referral centre, and the ‘spokes’ are more basic centres with limited or no lab facilities, but which are nearer to where people live. These sites have not previously been involved in research; some sites were new to delivering treatment services to HIV-infected individuals.