• Can We Get More HIV-Positive Tuberculosis Patients on Antiretroviral Treatment in a Rural District of Malawi?

      Zachariah, R; Teck, R; Ascurra, O; Gomani, P; Manzi, M; Humblet, P; Nunn, P; Salaniponi, F M L; Harries, A D; Medical Department (HIV-TB Operational Research), Brussels Operational Centre, Médecins sans Frontières, Brussels, Belgium. zachariah@internet.lu (International Union Against TB and Lung Disease, 2005-03)
      The World Health Organization (WHO) has set a target of treating 3 million people with antiretroviral treatment (ART) by 2005. In sub-Saharan Africa, HIV-positive tuberculosis (TB) patients could significantly contribute to this target. ART (stavudine/lamivudine/nevirapine) was initiated in Thyolo district, Malawi, in April 2003, and all HIV-positive TB patients were considered eligible and offered ART. Despite this, only 44 (13%) of 352 TB patients were eventually started on ART by the end of November 2003. Most TB patients leave hospital after 2 weeks to complete the initial phase of anti-tuberculosis treatment (rifampicin-based) in the community, and ART is offered to HIV-positive TB patients after they have started the continuation phase of treatment (isoniazid/ ethambutol). ART is only offered at hospital, while the majority of TB patients take their continuation phase of anti-tuberculosis treatment from health centres. HIV-positive TB patients therefore find it difficult to access ART. In this paper, we discuss a series of options to increase the uptake of ART among HIV-positive TB patients. The main options are: 1) to hospitalise HIV-positive TB patients with a view to starting ART in the continuation phase in hospital; 2) to decentralise ART delivery so ART can be delivered at health centres; 3) to replace nevirapine with efavirenz so ART can be started earlier in the initial phase of anti-tuberculosis treatment. Decentralisation of ART from hospitals to health centres would greatly improve ART access.
    • Special report: silent disasters.

      Eriksson, A; Medécins Sans Frontières, Stockholm, Sweden. anneli_eriksson@stockholm.msf.org (2007-12)
      Disasters occur not only in war and conflict or after natural events, such as earthquakes or floods. In fact, the death of hundreds of thousands of children in Niger every year, often for treatable conditions, could just as well qualify as a disaster situation. A lack of funding for health care and health-care staff and user fee policies for health care in very poor or unstable settings challenge international agreements that make statements about the right to health and access to health care for all people. This paper argues that although sustainable development is important, today many are without essential health care and die in the silent disasters of hunger and poverty. In other words, the development of health care appears to be stalled for the sake of sustainability.
    • Supervision, monitoring and evaluation of nationwide scale-up of antiretroviral therapy in Malawi

      Libamba, Edwin; Makombe, Simon; Mhango, Eustice; de Ascurra Teck, Olga; Limbambala, Eddie; Schouten, Erik J; Harries, Anthony D; Clinical HIV Unit, Ministry of Health, Lilongwe, Malawi; The Lighthouse Clinic, Lilongwe, Malawi; Médecins Sans Frontières–Belgium, Malawi Office, Blantyre, Malawi; World Health Organization Country Office, Lilongwe, Malawi; HIV Coordinator, Ministry of Health, Lilongwe, Malawi (2006-04-13)
      OBJECTIVE: To describe the supervision, monitoring and evaluation strategies used to assess the delivery of antiretroviral therapy during nationwide scale-up of treatment in Malawi. METHODS: In the first quarter of 2005, the HIV Unit of the Ministry of Health and its partners (the Lighthouse Clinic; Médecins Sans Frontières-Belgium, Thyolo district; and WHO's Country Office) undertook structured supervision and monitoring of all public sector health facilities in Malawi delivering antiretroviral therapy. FINDINGS: Data monitoring showed that by the end of 2004, there were 13,183 patients (5274 (40%) male, 12 527 (95%) adults) who had ever started antiretroviral therapy. Of patients who had ever started, 82% (10 761/13,183) were alive and taking antiretrovirals; 8% (1026/13,183) were dead; 8% (1039/13,183) had been lost to follow up; <1% (106/13,183) had stopped treatment; and 2% (251/13,183) had transferred to another facility. Of those alive and on antiretrovirals, 98% (7098/7258) were ambulatory; 85% (6174/7258) were fit to work; 10% (456/4687) had significant side effects; and, based on pill counts, 96% (6824/7114) had taken their treatment correctly. Mistakes in the registration and monitoring of patients were identified and corrected. Drug stocks were checked, and one potential drug stock-out was averted. As a result of the supervisory visits, by the end of March 2005 recruitment of patients to facilities scheduled to start delivering antiretroviral therapy had increased. CONCLUSION: This report demonstrates the importance of early supervision for sites that are starting to deliver antiretroviral therapy, and it shows the value of combining data collection with supervision. Making regular supervisory and monitoring visits to delivery sites are essential for tracking the national scale-up of delivery of antiretrovirals.
    • The Union and Médecins Sans Frontières approach to operational research.

      Harries, A D; Rusen, I D; Reid, T; Detjen, A K; Berger, S D; Bissell, K; Hinderaker, S G; Edginton, M; Fussell, M; Fujiwara, P I; et al. (2011-02)
      Operational research (OR) has become a hot topic at national meetings, international conferences and donor fora. The International Union Against Tuberculosis and Lung Disease (The Union) and Médecins Sans Frontières (MSF) Operational Centre Brussels strongly promote and implement OR with colleagues in low- and middle-income countries. Here we describe how the two organisations define OR, and explain the guiding principles and methodology that underpin the strategy for developing and expanding OR in those countries. We articulate The Union's and MSF's approach to supporting OR, highlighting the main synergies and differences. Then, using the Malawi National Tuberculosis Control Programme as an example, we show how OR can be embedded within tuberculosis control activities, leading to changes in policy and practice at the national level. We discuss the difficult, yet vitally important, issue of capacity building, and share our vision of a new paradigm of product-related training and performance-based OR fellowships as two ways of developing the necessary skills at country level to ensure research is actually performed. Finally, we highlight the need to consider and incorporate into practice the ethical components of OR. This is a key moment to be involved in OR. We are confident that in partnership with interested stakeholders, including the World Health Organization, we can stimulate the implementation of quality, relevant OR as an integral part of health service delivery that in turn will lead to better health for people, particularly for those living in the poorer parts of the world.