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Changing clinical needs of people living with AIDS and receiving home based care in Malawi--the Bangwe Home Based Care Project 2003-2008--a descriptive study.

Bowie C, Gondwe N, Bowie C - BMC Public Health (2010)

Bottom Line: There were significant barriers to accessing ART with 156 (51%) of 304 stage 3 or 4 patients first assessed in 2007 or 2008 not receiving ART.Over the six year period new HBC cases reduced by 8% and follow up visits increased by 9% a year.In terms of quantity of care the number of new patients seeking HBC reduced by 8% a year.In conclusion, although the content has changed the need for HBC has not diminished despite the availability of ART.

View Article: PubMed Central - HTML - PubMed

Affiliation: Division of Community Health, College of Medicine, Blantyre, Malawi. cam.bowie1@gmail.com

ABSTRACT

Background: Home based care (HBC) has been an important component of the response to the AIDS epidemic in Africa, and particularly so before antiretroviral therapy (ART) became available. Has HBC become unnecessary now that ART is available in many African countries? One way to investigate this is to assess the changing need for comprehensive HBC as an ART programme becomes available. The Bangwe HBC programme in Malawi has been collecting data since 2003 before ART became available in 2005/6. Has the introduction of ART changed the clinical needs for HBC?

Methods: Information obtained at initial assessment and follow up visits of patients receiving HBC were combined to assess case severity, survival and the response to treatment. This information was used to assess trends in mortality and the incidence, duration and severity of common symptoms over a six year period in a defined urban population in Malawi.

Results: 1266 patients, of whom 1190 were followed up and of whom 652 (55%) died, were studied. 282 (25%) patients died within two months of being first seen with an improvement between 2003-2005 and 2006-2008 of reduced mortality from 28% to 20%. 341 (27%) patients were unable to care for themselves on first assessment and 675 (53%) had stage 4 AIDS disease. Most patients had a mix of symptoms at presentation. Self care increased somewhat over the six years although case severity as measured by WHO staging and nutritional status did not.350 patients were on ART either started before or after initial assessment. There were significant barriers to accessing ART with 156 (51%) of 304 stage 3 or 4 patients first assessed in 2007 or 2008 not receiving ART.Over the six year period new HBC cases reduced by 8% and follow up visits increased by 9% a year. Between 4 and 5 people sought HBC for the first time each week from an urban health centre catchment of 100,000, which required 37.3 follow up visits each week.

Conclusions: Since the availability of ART in the local health facilities and despite strenuous efforts to persuade people to seek HIV testing and ART, in practice barriers existed and half the eligible HBC patients did not have access to ART. This is one reason why the clinical need for HBC services had not changed much. In terms of quantity of care the number of new patients seeking HBC reduced by 8% a year. In terms of content of care, while there had been a marginal increase in self care the severity of illness had not changed and the survival of a significant proportion of patients generated the need for repeat visits, which increased by 9% a year. In conclusion, although the content has changed the need for HBC has not diminished despite the availability of ART.

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Survival of Bangwe home based care patients 2003-2008 on or not on ART.
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Figure 3: Survival of Bangwe home based care patients 2003-2008 on or not on ART.

Mentions: Of the 1190 patients followed up, 652 (55%) died. 282 patients (25%) died within 2 months of being first seen and 403 (36%) died within the first four months. There was an improvement in 2 month mortality between the early period (2003-2005) and the late period (2006-2008) reducing from 28% to 20%. Longer term survival of more than six months did not change much between 2003 and 2005 but improved in 2006 and 2007 (Figure 2). Those on ART after HBC had a much improved survival, with 94% of patients surviving over 6 months, but those who were on ART at initial assessment had a high early mortality (Figure 3). Of the 852 who had been followed up and who had not received ART 574 (67%) died leaving 278 (33%) alive at the time of their last follow up. Of these 852 cases 37% survived one year, 25% two years, 21% three years, 18% four years and 16% five years (Table 3). For those eligible for ART (stage 3 and 4 patients) 34% survived one year, 23% two years, 19% three years, 16% four years and 15% five years. For these patients the differences of survival between last known reported HIV positive and unknown status were not statistically different (LogRank Chi-sq 1.32, 1df, p = 0.251).


Changing clinical needs of people living with AIDS and receiving home based care in Malawi--the Bangwe Home Based Care Project 2003-2008--a descriptive study.

Bowie C, Gondwe N, Bowie C - BMC Public Health (2010)

Survival of Bangwe home based care patients 2003-2008 on or not on ART.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2909166&req=5

Figure 3: Survival of Bangwe home based care patients 2003-2008 on or not on ART.
Mentions: Of the 1190 patients followed up, 652 (55%) died. 282 patients (25%) died within 2 months of being first seen and 403 (36%) died within the first four months. There was an improvement in 2 month mortality between the early period (2003-2005) and the late period (2006-2008) reducing from 28% to 20%. Longer term survival of more than six months did not change much between 2003 and 2005 but improved in 2006 and 2007 (Figure 2). Those on ART after HBC had a much improved survival, with 94% of patients surviving over 6 months, but those who were on ART at initial assessment had a high early mortality (Figure 3). Of the 852 who had been followed up and who had not received ART 574 (67%) died leaving 278 (33%) alive at the time of their last follow up. Of these 852 cases 37% survived one year, 25% two years, 21% three years, 18% four years and 16% five years (Table 3). For those eligible for ART (stage 3 and 4 patients) 34% survived one year, 23% two years, 19% three years, 16% four years and 15% five years. For these patients the differences of survival between last known reported HIV positive and unknown status were not statistically different (LogRank Chi-sq 1.32, 1df, p = 0.251).

Bottom Line: There were significant barriers to accessing ART with 156 (51%) of 304 stage 3 or 4 patients first assessed in 2007 or 2008 not receiving ART.Over the six year period new HBC cases reduced by 8% and follow up visits increased by 9% a year.In terms of quantity of care the number of new patients seeking HBC reduced by 8% a year.In conclusion, although the content has changed the need for HBC has not diminished despite the availability of ART.

View Article: PubMed Central - HTML - PubMed

Affiliation: Division of Community Health, College of Medicine, Blantyre, Malawi. cam.bowie1@gmail.com

ABSTRACT

Background: Home based care (HBC) has been an important component of the response to the AIDS epidemic in Africa, and particularly so before antiretroviral therapy (ART) became available. Has HBC become unnecessary now that ART is available in many African countries? One way to investigate this is to assess the changing need for comprehensive HBC as an ART programme becomes available. The Bangwe HBC programme in Malawi has been collecting data since 2003 before ART became available in 2005/6. Has the introduction of ART changed the clinical needs for HBC?

Methods: Information obtained at initial assessment and follow up visits of patients receiving HBC were combined to assess case severity, survival and the response to treatment. This information was used to assess trends in mortality and the incidence, duration and severity of common symptoms over a six year period in a defined urban population in Malawi.

Results: 1266 patients, of whom 1190 were followed up and of whom 652 (55%) died, were studied. 282 (25%) patients died within two months of being first seen with an improvement between 2003-2005 and 2006-2008 of reduced mortality from 28% to 20%. 341 (27%) patients were unable to care for themselves on first assessment and 675 (53%) had stage 4 AIDS disease. Most patients had a mix of symptoms at presentation. Self care increased somewhat over the six years although case severity as measured by WHO staging and nutritional status did not.350 patients were on ART either started before or after initial assessment. There were significant barriers to accessing ART with 156 (51%) of 304 stage 3 or 4 patients first assessed in 2007 or 2008 not receiving ART.Over the six year period new HBC cases reduced by 8% and follow up visits increased by 9% a year. Between 4 and 5 people sought HBC for the first time each week from an urban health centre catchment of 100,000, which required 37.3 follow up visits each week.

Conclusions: Since the availability of ART in the local health facilities and despite strenuous efforts to persuade people to seek HIV testing and ART, in practice barriers existed and half the eligible HBC patients did not have access to ART. This is one reason why the clinical need for HBC services had not changed much. In terms of quantity of care the number of new patients seeking HBC reduced by 8% a year. In terms of content of care, while there had been a marginal increase in self care the severity of illness had not changed and the survival of a significant proportion of patients generated the need for repeat visits, which increased by 9% a year. In conclusion, although the content has changed the need for HBC has not diminished despite the availability of ART.

Show MeSH