Implications of HIV treatment policies on the health workforce in rural Malawi and Tanzania between 2013 and 2017: Evidence from the SHAPE-UTT study

Figures & data

Table 1. Characteristics of facilities and in-depth interview participants.

Country		Malawi	Tanzania	Total
HDSS site name		Karonga	Ifakara
Size of HDSS site (km2)		135	2400
Population of HDSS site		42,555	170,000
HIV prevalence in the HDSS		9.60%	7%
Total number of facilities		5	12	17
Dates of facility survey data collection
	Round 1	Dec-13	Nov 2013–March 2014
	Round 2	May-15	Sept–Oct 2015
	Round 3	Nov–Dec 2017	Nov–Dec 2017
Size
	Dispensary	0 (0%)	2 (11%)	2
	Large clinic/small health centre	3 (60%)	4 (34%)	7
	Large health centre /sub-district hospital	2 (40%)	3 (25%)	5
	District hospital	0 (0%)	2 (17%)	2
	Referral hospital	0 (0%)	1 (8%)	1
Ownership
	Government	3 (60%)	10 (83%)	13
	Faith-based organization	2 (40%)	1 (8%)	3
	Private-for-profit	0 (0%)	1 (8%)	1
Health care workers
Lay workers		4	0	4
Non-physician health workers
	Midwife Nurse	3	4	7
	Registered nurse	0	1	1
	Nurse attendant	0	2	2
References for each HDSS site 1. Crampin, et al. ( 2012). 2. Geubbels, et al. ( 2015).

Figure 1. Conceptual Framework.

Table 2. Health workforce Summary.

	Policy guidance by 2013	Policy guidance by 2015	Policy guidance by 2017
INDICATOR 1: Type of health worker allowed to conduct HIV tests
Malawi	"HTC trained and certified staff, who are either health or non-health (lay) workers’ (Ministry of Health Malawi, 2009)	No new policy	Medical or non-medical HTC counsellors that have completed the nationally recognized HTC Counsellor Training Course(The Ministry of Health Malawi, 2016)
Tanzania	"At least Ordinary (O) Level education, received additional training or certification in health or a related field, trained and certified in national HTC training curricula, licensed by Laboratory with MOHSW as HIV tester"(Ministry of Health and Social Welfare National AIDS Control Programme (NACP), 2013)	No new policy	No new policy
WHO	"Lay counsellors working under supervision and with periodic mentoring can provide HTC’ (World Health Organization, 2008)	"Lay providers trained and supervised to use rapid diagnostic tests (RDTs) can independently conduct HTC"(World Health Organization, 2013)	No change in content(World Health Organization, 2016)
INDICATOR 2: Type of health workers that can initiate ART,
Malawi	"Medical officers, clinical officers, medical assistants and nurses can initiate and prescribe ARVs … if they have attended an ART training course recognized by the Ministry of Health"(Ministry of Health Malawi, 2008, 2011)	No change in content(Ministry of Health Malawi, 2014)	No change content (Ministry of Health Malawi, 2016)
Tanzania	"Only trained and authorized prescribers in certified health care facilities are allowed to write ARV prescriptions"(Ministry of Health and Social Welfare National AIDS Control Programme (NACP), 2012)	No change in content (Ministry of Health and Social Welfare National AIDS Control Programme (NACP), 2015)	No change content (Ministry of Health and Social Welfare National AIDS Control Programme (NACP) 2017)
WHO	"Trained non-physician clinicians, midwives and nurses can initiate first-line ART and can maintain ART and dispense ART"(World Health Organization, 2013)	No new policy	No change in content (World Health Organization, 2016)
INDICATOR 3: Training and refresher training for staff providing ART, PMTCT, HTC
Malawi	All staff must undertake a 5-day ART training course followed by annual refresher ART training courses (Ministry of Health Malawi, 2008)	PMTCT/ART refresher trainings based on new guidelines (2nd Edition of the Clinical Guidelines) should be carried out during roll out(Ministry of Health Malawi, 2014)	"refresher trainings be provided to all practicing HTC providers every two years and from time to time based on need and changes in the guidelines"(The Ministry of Health Malawi, 2016)
Tanzania	Two types of training required for HTC: Pre-placement training and at least one annual refresher training (Ministry of Health and Social Welfare National AIDS Control Programme (NACP), 2013)	‘Training for ART and adherence should be offered and updated periodically for all health care team members’ (Ministry of Health and Social Welfare National AIDS Control Programme (NACP), 2015)	No change in content(Ministry of Health and Social Welfare National AIDS Control Programme (NACP) 2017)
WHO	"All health workers assigned to perform point of-care tests must be trained and proficient on the testing procedure’ (World Health Organization, 2013). ‘Trained non-physician clinicians, midwives and nurses can initiate first-line ART ‘(World Health Organization, 2013)	No new policy	No change in content (World Health Organization, 2016)
INDICATOR 4: Number of staff required for a facility offering HTC, ART, PMTCT
Malawi	‘The health facility will determine the number and type of staff needed to run the ART Clinic … the minimum staff requirement is: 1 clinician 1 nurse 1 ward clerk equivalent’(Ministry of Health Malawi, 2008)	No new policy	Facilities implementing the new policies should have at least 2 health workers that have had training for the new guidelines. (Ministry of Health Malawi, 2016)
Tanzania	A team consisting of at least 3 members, at least 1 clinician, at least 1 adherence counselor, at least 1 other health worker (Ministry of Health and Social Welfare National AIDS Control Programme (NACP), 2012)	No change in content (Ministry of Health and Social Welfare National AIDS Control Programme (NACP), 2015)	No change in content (Ministry of Health and Social Welfare National AIDS Control Programme (NACP) 2017)
WHO	1–100 HIV positive patients per year: 0–1 clinical provider and 1–2 lay providers. 101–250 patients: 1 clinical provider, 1 clerk and 2 lay providers. 251–500 patients: 1–2 additional clinical providers: 1 clerk/triage officer and three lay providers. 500–750 patients 2 clinical providers 1 clerk/triage officer and 4 lay providers (World Health Organization, 2008)	"Tools such as the WHO Workload Indicator for Staffing Need (WISN) can be useful to calculate the number of health workers and lay providers needed to provide adequate HTC."(World Health Organization, 2015a)	No change in content(World Health Organization, 2016)
INDICATOR 5: Number of counselling sessions that a counsellor is allowed to perform per day
Malawi	Recommended number of clients to be seen by each counsellor at a VCT site is between 8 and 15, (Ministry of Health Malawi, 2009)	No new policy	‘number of clients to be seen by each counselor must be within the range of what is practically possible when all standard HTC protocols are followed’(The Ministry of Health Malawi, 2016)
Tanzania	Not stated in policy	Not stated in policy	Not stated in policy
WHO	Not Stated in guidance	Not stated in guidance	Not stated in guidance

Table 3. List of documents reviewed in policy review.

	Malawi Policy Documents	Year
1	2016 3rd Edition of Guidelines for the Clinical Management of HIV in Children and Adults.	2016
2	2016 Malawi HIV Testing Services (HTC) Guidelines.	2016
3	National Strategic plan for HIV and AIDS (2015-2020).	2015
4	2015 Viral Load Strategic Scale Up Plan: Increasing Access to Viral Load Testing in Malawi	2015
5	2014 2nd Edition of the Malawi Guidelines for Clinical Management of HIV in Children and Adults	2014
6	2012 National HIV and AIDS policy July 2011-June 2016	2012
7	2011 Malawi National HIV and AIDS Strategic Plan 2011–2016	2011
8	2011 Clinical Management of HIV in Children and Adults: Malawi Integrated Guidelines	2011
9	2010 Prevention of Mother to child transmission of HIV and pediatric HIV care guidelines	2010
10	2009 Guidelines for HIV testing and counselling 3rd Edition	2009
11	2008: Guidelines for the use of ART in Malawi, 3rd edition	2008
12	The 5-year plan to scale up HCT services in Malawi 2006–2010	2006
13	2006: Guidelines for the use of ART in Malawi, 2nd edition	2006
14	2003: Guidelines for the use of ART in Malawi, 1st edition	2003
	Tanzania Policy Documents	Year
15	National Guidelines for the Management of HIV and Aids: six edition October	2017
16	National Guidelines for the Management of HIV and Aids: fifth edition May	2015
17	National Health sector strategic Plan 2015–2020	2015
18	Human Resource for Health Country Profile	2013
19	National Comprehensive Guidelines for HIV Testing and Counselling	2013
20	National Guidelines for the Management of HIV and AIDs. Fourth edition	2012
21	Antenatal Care Guidelines	2010
22	Human Resource for Health Strategic Plan	2008
23	Tanzania Health policy	2007
24	National PITCT Guidelines	2007
25	National Guideline on VCT	2005
	WHO Policy Documents	Year
26	Consolidated guidelines for the Use of ART for Treating and Preventing HIV Infection 2016	2016
27	Consolidated Guidelines on HIV Testing Services 2015	2015
28	Guidelines on Patient-Centered HIV patient monitoring and case surveillance 2017	2017
29	Consolidated Strategic Information Guidelines 2015	2015
30	March 2014 supplement to the 2,013 consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection	2014
31	Consolidated Guidelines for Prevention, Diagnosis, Treatment and Care for Key Populations ‘	2016
32	Guidelines on HIV Self-Testing and Partner Notification	2016
33	Consolidated guidelines for the Use of ART for Treating and Preventing HIV Infection 2013	2013
34	Operations Manual for Delivery of HIV Prevention, Care and Treatment at Primary Health Centers in High-Prevalence, Resource-Constrained Settings	2008
35	Guidance on provider-initiated HIV testing and counselling in health facilities	2007

Figure 2. Mean number of providers by cadre and facility by round and HDSS

Figure 3. HTC, PMTCT and ART total patient visits and visits or tests per provider

Figure 4. (a): The Number of Providers and proportions trained in the delivery of HTC, ART and PMTCT in Karonga. (b): The Number of Providers and proportions trained in the delivery of HTC, ART and PMTCT in Ifakara.

Crampin, A. C., Dube, A., Mboma, S., Price, A., Chihana, M., Jahn, A., Baschieri, A., Molesworth, A., Mwaiyeghele, E., Branson, K., Floyd, S., McGrath, N., Fine, P. E. M., French, N., Glynn, J. R., & Zaba, B. (2012). Profile: The Karonga health and demographic surveillance system. International Journal of Epidemiology, 41(3), 676–685. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3396313/. https://doi.org/10.1093/ije/dys088

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