Expansion of Antiretroviral Treatment to Rural Health Centre Level by a Mobile Service in Mumbwa District, Zambia/Elargissement De L'acces Au Traitement Antiretroviral Au Niveau Des Centres De Sante Ruraux Grace a Un Service Mobile Dans le District De Mumbwa. Zambie/Expansion del Tratamiento Antirretroviral a Nivel De Los Centros De Salud Rurales Mediante Un Servicio Movil En El Distrito De Mumbwa, Zambia

Introduction Zambia is one of the sub-Saharan African countries worst affected by the HIV pandemic. In 2007, the prevalence rate among adults was approximately 14.3% and there were an estimated 1.5 million HIV-infected people. (1,2) In 2004, the government of Zambia declared HIV/AIDS a national crisis and launched a policy of free antiretroviral treatment (ART), that made free ART available in 322 sites. (2,3) However, more than half of the population lives in rural areas where there is poor access to ART services. (1) Several studies reported that long travel distances are a potential barrier to accessing services and, after starting ART, they are a barrier to optimal adherence (2-6) To improve accessibility, ART services need to be located as close to the community as possible. Thus, Mumbwa district health management team introduced a mobile ART service at rural health centres as a pilot programme of the Ministry of Health. This paper discusses the uptake of these mobile services in rural Mumbwa. Local setting Mumbwa District is one of 72 districts in Zambia, with an area of 23000 [km.sup.2] and a population of 167 000. There are 28 public health facilities including a district hospital, as well as a mission hospital and private facilities. Health-care providers in the whole district consist of five medical doctors, 24 clinical officers, 44 nurses and 33 midwives. The district hospital plays a role as a referral hospital for care, support and treatment of HIV. It is equipped with an X-ray machine, a blood cell counter, a biochemistry analyzer, a CD4+ lymphocyte (CD4) counter, a microscopic examination and urinalysis. Rural health centres are usually staffed by only two to four medical professionals such as clinical officers, nurses and/or an environmental health technician. They offer simple examinations such as rapid tests while X-ray examination and most laboratory services including haemoglobin are only available in hospitals. In 2006, ART services were provided only at Mumbwa District Hospital. The number of clients receiving ART was less than 450 in April 2006, although the number of clients in need of ART was estimated approximately 5000 to 7500. Approach Mobile ART services commenced at four rural health centres in the first quarter of 2007. Before the implementation of the services, staff members at the four sites attended a 10-day training course in management of ART and optimistic infection conducted by the experienced staff of the district health management team and Mumbwa District Hospital. Lay counsellors and support group members, of whom most are HIV-positive and on ART, were selected from the community and trained in HIV prevention, ART and counselling skills to assist staff members in the rural health centres. Almost daily, lay counsellors gave psychosocial counselling to ART patients in the community, and support group members reminded them of the arrival of the mobile service. Rural health centres were selected as mobile ART sites according to geographical location, coverage population and existing resources including medical staff, space and community activities. A mobile ART team including a medical doctor, clinical officer, nurse, laboratory staff and pharmacist visited the ART sites every two weeks. [FIGURE 1 OMITTED] Eligibility for the mobile ART services was assessed by either CD4 cell count (for which blood samples were sent to the district hospital laboratory) or clinical symptoms. Eligible patients were monitored in the same manner as the hospital by trained professionals either from the mobile team or ones from the rural health centre depending on staff availability in the health centre. However, complicated cases that could not be treated by the mobile service were transferred to the hospital. Operational cost for the four mobile ART services expended by the district health management team, which was the only source of funding, was 86 million kwacha per year (approximately 17 000 United States dollars) which included allowances for team members, fuel and motor vehicle services. …