Abstract
BackgroundIn Malawi, high case fatality rates in patients with tuberculosis, who were also co-infected with HIV, and high early death rates in people living with HIV during the initiation of antiretroviral treatment (ART) adversely impacted on treatment outcomes for the national tuberculosis and ART programmes respectively. This article i) discusses the operational research that was conducted in the country on cotrimoxazole preventive therapy, ii) outlines the steps that were taken to translate these findings into national policy and practice, iii) shows how the implementation of cotrimoxazole preventive therapy for both TB patients and HIV-infected patients starting ART was associated with reduced death rates, and iv) highlights lessons that can be learnt for other settings and interventions.DiscussionDistrict and facility-based operational research was undertaken between 1999 and 2005 to assess the effectiveness of cotrimoxazole preventive therapy in reducing death rates in TB patients and subsequently in patients starting ART under routine programme conditions. Studies demonstrated significant reductions in case fatality in HIV-infected TB patients receiving cotrimoxazole and in HIV-infected patients about to start ART. Following the completion of research, the findings were rapidly disseminated nationally at stakeholder meetings convened by the Ministry of Health and internationally through conferences and peer-reviewed scientific publications. The Ministry of Health made policy changes based on the available evidence, following which there was countrywide distribution of the updated policy and guidelines. Policy was rapidly moved to practice with the development of monitoring tools, drug procurement and training packages. National programme performance improved which showed a significant decrease in case fatality rates in TB patients as well as a reduction in early death in people with HIV starting ART.SummaryKey lessons for moving this research endeavour through to policy and practice were the importance of placing operational research within the programme, defining relevant questions, obtaining "buy-in" from national programme staff at the beginning of projects and having key actors or "policy entrepreneurs" to push forward the policy-making process. Ultimately, any change in policy and practice has to benefit patients, and the ultimate judge of success is whether treatment outcomes improve or not.
Highlights
In Malawi, high case fatality rates in patients with tuberculosis, who were co-infected with HIV, and high early death rates in people living with HIV during the initiation of antiretroviral treatment (ART) adversely impacted on treatment outcomes for the national tuberculosis and antiretroviral therapy (ART) programmes respectively
As an example of how this can work at the national level for TB and ART programmes and how guiding principles of operational research are put into practice, we describe the operational research that was carried out in Malawi with cotrimoxazole preventive therapy (CPT), initially in HIV-infected tuberculosis (TB) patients and all HIV-infected patients starting ART
The first showed a decrease in morbidity in HIV-infected adults [7], while the second conducted in HIV-infected patients with TB showed a significant reduction in mortality [8]. These studies persuaded the Joint United Nations Programme on AIDS (UNAIDS) to issue provisional recommendations in 2000 that all people living with HIV (PLHIV) in Africa who were symptomatic should receive CPT as part of a standard package of care [9]
Summary
Effect of HIV on increasing death rates and reducing cure rates in the Malawi TB Control Programme Malawi is a small country in southern Africa with a current population of about 13 million. From policy to practice: scaling up of cotrimoxazole preventive therapy for people living with HIV and impact on early deaths on antiretroviral therapy Following the adoption of the policy, the HIV department of the MoH wrote a circular with guidelines on CPT drug regimens and individual patient supplies, contraindications, duration of therapy, recruitment, followup monitoring and evaluation and drug supply issues This circular was distributed country-wide for immediate use, and national ART guidelines were eventually updated based on the new evidence [32]. List of abbreviations used AIDS: acquired immune deficiency syndrome; ART: antiretroviral therapy; CPT: cotrimoxazole preventive therapy; DOTS: directly observed treatment, short course; GFATM: Global Fund to fight AIDS, TB and malaria; HIV: human immunodeficiency virus; IMCI: Integrated Management of Childhood Illness; MoH: Ministry of Health; NTP: national tuberculosis control programme; PLHIV: people living with HIV. Competing interests The authors declare that they have no competing interests
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