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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

Bello, George, Faragher, Brian, Sanudi, Lifah, Namakhoma, Ireen, Banda, Hastings, Malmborg, Rasmus, Thomson, Rachael and Squire, Bertie ORCID: https://orcid.org/0000-0001-7173-9038 (2017) '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'. PLoS ONE, Vol 12, Issue 9, e0183312.

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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.

Item Type: Article
Subjects: WA Public Health > WA 30 Socioeconomic factors in public health (General)
WA Public Health > Health Administration and Organization > WA 546 Local Health Administration. Community Health Services
WC Communicable Diseases > Virus Diseases > Acquired Immunodeficiency Syndrome. HIV Infections > WC 503.1 Diagnosis
WF Respiratory System > Tuberculosis > WF 220 Diagnosis. Prognosis
Faculty: Department: Biological Sciences > Department of Tropical Disease Biology
Clinical Sciences & International Health > Clinical Sciences Department
Digital Object Identifer (DOI): https://doi.org/10.1371/journal.pone.0183312
SWORD Depositor: JISC Pubrouter
Depositing User: JISC Pubrouter
Date Deposited: 22 Sep 2017 14:40
Last Modified: 22 Sep 2017 14:40
URI: https://archive.lstmed.ac.uk/id/eprint/7573

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