Implementing Antiretroviral Therapy in Rural Communities: The Lusikisiki Model of Decentralized HIV/AIDS Care

Abstract

Health worker shortages are a major bottleneck to scaling up antiretroviral therapy (ART), particularly in rural areas. In Lusikisiki, a rural area of South Africa with a population of 150,000 serviced by 1 hospital and 12 clinics, Médecins Sans Frontières has been supporting a program to deliver human immunodeficiency virus (HIV) services through decentralization to primary health care clinics, task shifting (including nurse-initiated as opposed to physician-initiated treatment), and community support. This approach has allowed for a rapid scale-up of treatment with satisfactory outcomes. Although the general approach in South Africa is to provide ART through hospitals-which seriously limits access for many people, if not the majority of people-1-year outcomes in Lusikisiki are comparable in the clinics and hospital. The greater proximity and acceptability of services at the clinic level has led to a faster enrollment of people into treatment and better retention of patients in treatment (2% vs. 19% lost to follow-up). In all, 2200 people were receiving ART in Lusikisiki in 2006, which represents 95% coverage. 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.

Adherence to antiretroviral therapy, virologic failure and workload at the Rustenburg Provincial Hospital

“…21,37 Decentralisation of services and task shifting as practised in Lusikisiki and the Free State should be considered and rolled out nationally to alleviate the problems of capacity at major ART clinics. [38][39][40] There is now considerable evidence across Africa of the feasibility of integrated district-based approaches that achieve universal access while maintaining quality and outcomes. 26,37,41,42 Providing ART at the primary health care clinic level increases the number of entry points to care, while the greater proximity of services encourages retention in care.…”

Task shifting in HIV/AIDS: opportunities, challenges and proposed actions for sub-Saharan Africa

“…Community health workers have had a significant positive impact, particularly on reducing mortality linked to childhood pneumonia, 20 malaria 21 and tuberculosis (TB). 22 In HIV care the deployment of lay counsellors has resulted in a dramatic uptake of HIV testing services in Thyolo, Malawi (Figure 2), 23 Lusikiski, South Africa, 19 and Lesotho. 8 Communities can also contribute in a comprehensive manner to ART delivery as seen in Malawi (Table 3).…”

“…Evidence from Lusisiki in South Africa and Thyolo in Malawi showed that the use of nurses (Type II task shifting) 19 and community cadres (Type IV task shifting) 24 in the delivery of ART significantly improved overall ART outcomes (Table 4). Thus, from a public health perspective, the use of task shifting for HIV/AIDS care at two relatively new levels of the health system (health centres and the community) did not compromise quality but, on the contrary, was associated with significantly better ART outcomes.…”

“…36 In Malawi, Lesotho and Lusikisiki MSF provided theoretical and practical training for nurses, introduced tools adapted for nurses and provided on-site clinical mentoring, with good associated patient outcomes. 8,19,24 Accreditation of individuals and sites is one way to ensure that health workers have the necessary skills and capacity for specific interventions and that these are maintained over time. If standards are not met accreditation should be suspended or removed, as is practiced in Malawi for the delivery of ART.…”

Task shifting for antiretroviral treatment delivery in sub-Saharan Africa: not a panacea

“…Furthermore, although medical doctors are commonly perceived as the guardians of technical quality, a clinical approach isolated from the community is not ideal. The involvement of other cadres 11 and communities in support and care [12][13][14] brings benefi ts by increasing coverage and improving overall outcomes. 11,13 Patients, health staff , and policy makers need to be involved in setting measurable targets and indicators for what they deem to be an acceptable level of quality of care.…”