With approximately 930,000 infected persons (adults and children), Malawi has one of the world's highest HIV/AIDS rates. Twelve percent of the population between the ages of 15 and 49 is affected and 68,000 people die from the disease every year.

More than 13,000 of Médecins Sans Frontières (MSF)'s patients receive ARVs. But although 211 national facilities were offering ARVs free of charge by late 2008, only 50 percent of patients had access to the drugs and another 290,000 were still awaiting treatment.

"Every month, MSF places an additional 300 to 350 patients on ARVs," said Mickaël le Paih, the head of mission. "The needs are immense."

Cooperating, decentralizing, providing care closer to home

Given the extent of the needs and the shortage of health care staff - 40 percent of health care positions are vacant and very difficult to fill - Chiradzulu, and the rest of the country, required new treatment approaches. In collaboration with district health authorities, MSF simplified treatment protocols and delegated responsibility for treatment to the area's health care centers.

"In concrete terms, MSF medical staff work closely with Health Ministry staff in the health care centers on a daily basis," Mickaël le Paih explained. "That means we are sharing the work."

The goals of decentralized treatment are to ensure access to care and ARVs for the maximum number of the district's HIV patients and to provide services closer to home.

"Patients no longer have to walk miles to reach the hospital," said Séverine Doumeizel, the project coordinator. "They also receive better medical follow-up because in the event of complication, or if they don't feel well, it's simpler and faster for them to come back to the center."

Nouma leaves the MSF examination room at the Bilal health center. He entered MSF's program in 2008. Because he developed a resistance to the first-line drugs, he recently began taking second-line drugs.

"It was complicated to go to the district hospital," he said. "It is hard for me to walk and I don't have a car. And it's difficult to pay for transportation because it's far away. It takes me 30 minutes to reach the health center from my house.”

Creating accountability and delegating

To achieve the goal of reducing medical staff workloads - and thanks to treatment advances - some patients may be seen in the center twice a year and have their prescriptions renewed quarterly.

"There are several inclusion criteria for this program," explained Isaak, the project supervisor. "The patient must be taking a first-line treatment, must have followed the drug regime properly for more than a year and CD4 levels (markers of immunosuppression) must be above 350. If the patient is female, she must not be pregnant."

The idea is to emphasize treatment education for patients and to give them greater responsibility. In May 2009, 740 patients took advantage of this "streamlined" monitoring. In the event of a problem or complication, they may go directly to the health center, without waiting for their appointment date.

The strategy of assigning responsibilities to lower-level health care employees, and sometimes, to non-professionals, that are generally reserved to higher-level health professionals is widespread in developing countries. It is one way to deal with human resource shortages. In Malawi, some medical responsibilities have been delegated to nurses because of their greater number. They have been trained to initiate ARV treatment and monitor stable patients and can now provide care usually offered by physicians.

Only the most sensitive or complicated cases are referred to "clinical officers," health workers who have received four-years of medical training, but who are also in short supply.

Listening and Advising

Non-specialized, trained staff also handle screening and provide psychosocial and nutritional support. A patient taking ARVs must understand and specifically agree to continue the treatment for the rest of his or her life. This requires close and regular support, which is why MSF set up a counseling team to complement medical monitoring. The counselors are there to help patients with the daily problems that HIV poses and to ensure that they take their medications regularly.

Specific approaches have been set up for children, who represent 10 percent of patients. Communications tools intended for children ages 7 to 14 have been designed to provide them appropriate information on their illness.

"We know that it's important to get to the issue of HIV status quickly with children," says Violet, a psychosocial counselor. "And that means starting at the age of six. Most patients who learned about their illness after the age of 14 or 15 have a hard time taking their medicine properly. You have to talk with the children a lot and get involved with them."

What about the future?

All these evolutions have been conducted in close cooperation with the Ministry of Health. MSF expects to transfer increasing levels of responsibility to the agency.

"The decentralization goal was established in 2005," Le Paih said. "It's finally been achieved. Access to high-quality HIV care is available on a widespread basis throughout the Chiradzulu district. We're tempted to think about the longer-term now, which would, of course, involve the possibility of handing over MSF's activities over the course of several years."

But even if these innovative methods of delegating treatment responsibility provide relief to health staff and allow new patients to enter treatment quickly, they are not implemented on a national scale and do have limits.

"Even if the entire population could be screened tomorrow, the Ministry of Health would still face the human resources issue," Doumeizel noted. "And MSF cannot hire lots of people, for both financial and logistical reasons. The Ministry of Health must also continue to expand its ability to treat and monitor HIV patients."

In the meantime, MSF continues to develop programs like the prevention of mother-to-child HIV transmission (a transmission prevention program has been offered in these health centers since March 2008, using tritherapy on a prophylactic basis). Programs also include pediatric care and detecting treatment failures.

Thanks to MSF's program, more than 4,377 new patients received ARV treatment in Chiradzulu district in 2008. Since the project was initiated in 2001, MSF has monitored and treated about 13 000 patients.