The effect of engaging unpaid informal providers on case detection and treatment initiation rates for TB and HIV in rural Malawi (Triage Plus): A cluster randomised health system intervention trial
George Bello, Brian Faragher, Lifah Sanudi, Ireen Namakhoma, Hastings Banda, Rasmus Malmborg, Rachael Thomson, S Bertel Squire, George Bello, Brian Faragher, Lifah Sanudi, Ireen Namakhoma, Hastings Banda, Rasmus Malmborg, Rachael Thomson, S Bertel Squire
Abstract
Background: The poor face barriers in accessing services for tuberculosis (TB) and Human Immuno-deficiency Virus (HIV) disease. A cluster randomised trial was conducted to investigate the effectiveness of engaging unpaid informal providers (IPs) to promote access in a rural district. The intervention consisted of training unpaid IPs in TB and HIV disease recognition, sputum specimen collection, appropriate referrals, and raising community awareness.
Methods: In total, six clusters were defined in the study areas. Through a pair-matched cluster randomization process, three clusters (average cluster population = 200,714) were allocated to receive the intervention in the Early arm. Eleven months later the intervention was rolled out to the remaining three clusters (average cluster population = 209,564)-the Delayed arm. Treatment initiation rates for TB and Anti-Retroviral Therapy (ART) were the primary outcome measures. Secondary outcome measures included testing rates for TB and HIV. We report the results of the comparisons between the Early and Delayed arms over the 23 month trial period. Data were obtained from patient registers. Poisson regression models with robust standard errors were used to express the effectiveness of the intervention as incidence rate ratios (IRR).
Results: The Early and Delayed clusters were well matched in terms of baseline monthly mean counts and incidence rate ratios for TB and ART treatment initiation. However there were fewer testing and treatment initiation facilities in the Early clusters (TB treatment n = 2, TB testing n = 7, ART initiation n = 3, HIV testing n = 20) than in the Delayed clusters (TB treatment n = 4, TB testing n = 9, ART initiation n = 6, HIV testing n = 18). Overall there were more HIV testing and treatment centres than TB testing and treatment centres. The IRR was 1.18 (95% CI: 0.903-1.533; p = 0.112) for TB treatment initiation and 1.347 (CI:1.00-1.694; p = 0.049) for ART initiation in the first 12 months and the IRR were 0.552 (95% CI:0.397-0.767; p<0.001) and 0.924 (95% CI: 0.369-2.309, p = 0.863) for TB and ART treatment initiations respectively for the last 11 months. The IRR were 1.152 (95% CI:1.009-1.359, p = 0.003) and 1.61 (95% CI:1.385-1.869, p<0.001) for TB and HIV testing uptake respectively in the first 12 months. The IRR was 0.659 (95% CI:0.441-0.983; p = 0.023) for TB testing uptake for the last 11 months.
Conclusions: We conclude that engagement of unpaid IPs increased TB and HIV testing rates and also increased ART initiation. However, for these providers to be effective in promoting TB treatment initiation, numbers of sites offering TB testing and treatment initiation in rural areas should be increased.
Trial registration: ClinicalTrials.gov NCT02127983.
Conflict of interest statement
Competing Interests: SBS, BF and RT are employed by the Liverpool School of Tropical Medicine (LSTM) which is a registered charitable, UK-based research and teaching institution. Its mission is to save lives in resource poor countries through research, education and capacity strengthening. LSTM, in collaboration with REACH Trust, Malawi, applied to LHL for funds to carry out the work described in this manuscript. RM works for LHL International which is a Norwegian Non-Governmental Organisation (NGO) that receives funding from NORAD and the ATLAS Alliance (an umbrella organisation consisting of Norwegian NGO's working with people with disabilities and the fight against TB). LHL International is a member of the ATLAS Alliance. Funding from the ATLAS Alliance comes from individual Norwegian citizens who have given non-earmarked donations. LHL International, using funding as described above, is the funder of the Triage-plus project and therefore also of this article. While RM had no decision on whether or not the article was to be written and published, he had both technical input and financial management responsibility for funding of the project, in addition to being involved in the actual writing and work linked to being an author of this article. GB, LS, IM and HB are employed by the Research for Equity and Community Health Trust (REACH Trust) which is a registered charitable, local NGO based in Malawi. It's mission is to address the inequity in access to health services through research. REACH Trust in collaboration with LSTM, applied to LHL for funds to carry out the work described in this manuscript. This does not alter our adherence to PLOS ONE policies on sharing data and materials.
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