Communities provide HIV and tuberculosis care in Malawi

Malawi’s health service is struggling under the burden of HIV and AIDS and tuberculosis (TB). Its health workforce has only limited capacity to cope due to severe staff shortages, poor salaries and working conditions, high levels of HIV and AIDS-related deaths and chronic absenteeism due to illness among staff.

Without a strong healthworkforce, community members may have an important role to play in providingHIV and TB care. Médecins Sans Frontièresdescribes an example of community involvement in district level HIV and TB care.The study focuses on Thyolo district, a rural regionof southern Malawi with 458,976 inhabitants, of which an estimated 41,000 areliving with HIV. It covers a two-year period from January 2003 to December2004.

A package of community-basedactivities was designed in close collaboration with community representatives. Volunteersundergo training and those giving home-based care carry a kit with basic drugsand supportive material. In families where individuals are in the advancedstages of HIV, one member is trained as a ‘family caregiver.’ The volunteersare supervised by teams of peer leaders and community nurses, and areremunerated through a variety of incentives. A revolving fund has been createdthrough revenue generated by selling the produce of community farms. Monitoringis conducted through patient cards and activity reports.

Key findings include:

• Community membersran 12 of the 14 voluntary counselling and HIV testing (VCT) sites andconducted 41 percent of all HIV testing in the district.
• By the end of thestudy period, the community team comprised 465 home-based care (HBC)volunteers, 1,362 family caregivers and 9 community nurses caring for 5,106people with HIV.
• 2,714 TBpatients, of whom 60 percent also had HIV, were followed up on a monthly basisin the community.
• Volunteersscreened and referred cases of chronic cough for TB testing. A total of 806people were referred of which 161 tested positive for TB - indicating that onein five of these individuals have TB.
• Community groupsprovided care, pre-school activities and vocational training for AIDS orphans,and community vegetable gardens and maize farms provide food for poorindividuals and households.
• Communityvolunteers referred an average of 422 individuals each month to differentservices at health facilities.

The community in Thyolo is playing a vital role in helping to scale-up HIVand AIDS and TB activities and providing home-based care. Their activities haveachieved success in active screening for TB and are likely to have positivelyinfluenced health-seeking behaviour. Policy lessons include:

• Community care islikely to yield important savings for health services and both direct andindirect benefits to patients.
• Individuals withchronic coughs should be referred to health facilities.
• Community ledactivities to mitigate the impact of HIV and AIDS on families and orphans bringdignity and hope to many.
• Communitiesshould not be exploited by simply leaving government responsibilities tocommunities.
• The skills ofdistrict health representatives and collaborating partners in creating thenecessary dynamic between health workers and communities to forge collectiveownership are crucial.
• A threshold maybe reached where volunteers will have too many demands on their time.  Countries with high HIV rates may considerintroducing specific ‘remunerated’ community AIDS workers as formal healthworkers within the public health service in order to sustain communityactivities without threatening the livelihoods of those involved.