Since arriving in 2007, MSF has prioritized decentralizing HIV and TB services from the hospital and two health centers in the bigger towns, to the 22 primary health clinics across the Shiselweni region. Shiselweni is the most rural and poorest region of the country, which can make accessing care a real challenge. Even something like transport (which I have always taken for granted) is a real obstacle for many patients. Patients may walk 10km (each way) to their clinic. The ability to diagnose and treat the co-epidemics at the rural clinics has been supported by decentralizing laboratory and counseling services to these clinics in conjunction with the task shifting (I discussed this in a previous post).
To make critical lab testing available for all patients, MSF has placed mini-labs in the clinics staffed by trained lay people. These labs are focused on HIV/TB tests and are able perform CD4 counts, biochemistry follow-ups, and collect samples for viral loads to be run at the main lab. Each of the three zones have a main lab at the health centers and one zone (Nhlangano) has two additional labs, one dedicated to TB and one to viral load testing. The TB lab in Nhlangano is able to do drug susceptibility testing on thin layer agar, Löwenstein–Jensen culture, microscopic follow-up and GeneXpert (which allows for early detection of drug-resistant TB). The viral lab tests all the samples from the region, which are approximately 2000 samples per month (and growing). The results of these tests will help to quickly identify potential adherence or resistance issues, providing important information to the team on the next steps for the patient (treatment changes or additional counseling on the importance of adherence to medications). Detecting resistance early is critical for positive outcomes.
In early 2013, programs were initiated to increase counseling services through HIV Testing and Counseling / Expert Clients in the clinics. The people in these roles are living with HIV and have been trained to provide insights into their experiences, offering meaningful support to patients. Having lay people in the role of health counselors requires ongoing training and in 2014, the focus of training will be on methods for enhancing patient adherence to therapy.
There are many obstacles to adherence and the ones I hear a most often are about the unsupportive partners who will destroy the patient’s medications or stop them from going to the clinic for care. Unfortunately, there remains a stigma with an HIV diagnosis. Having support in the community, especially by those who can relate to these challenges, is essential. Comprehensive outreach related to anti-retroviral treatment is planned to be implemented with the Ministry of Health through treatment clubs and “Community ART Groups”, following successful models implemented in Mozambique and South Africa. For drug resistant TB patients, “Community Treatment Supporters” and treatment support groups is an important part of this work.
A major responsibility of the MSF pharmacy staff in this decentralized model is to support the Ministry of Health (MoH) and Central Medical Stores (CMS) by ensuring all of the essential medications for HIV, TB and the associated complications are consistently available in each clinic. MSF focuses on filling the gaps when the MoH is facing a challenge with their supply and we are the primary supplier of second-line TB drugs (working with the Green Light Committee) in Shiselweni. We work in partnership with Swaziland’s National AIDs Program and the National TB Control Program to quantify and forecast the medications needed, including the impact new treatment guidelines will have on the supply. The MoH/CMS supports more than 190 facilities across the country and so the MSF focus on 22 clinics, 2 health centers, 1 hospital, and 1 TB ward almost seems simple!