In 2004, Dignitas International began implementing a project focused on HIV prevention and treatment in Zomba District, Malawi, in order to address the high morbidity and mortality associated with AIDS in the district.  This response was at the request of the Malawi Ministry of Health (MoH) and Zomba District Health Office (DHO), and the program aligned with their priorities.  At the beginning there was no site for antiretroviral treatment (ART) in the district, and the program focused on establishing a decentralised community-based care model of HIV treatment, bringing treatment ever closer to the rural areas where most persons requiring HIV/AIDS treatment live in order to improve access to care.

Starting from a single clinic providing AIDS treatment in the district hospital, the program has decentralised HIV/AIDS care to 16 rural health centers in the district, and more than 8,000 adults and children receive ART at 16 health centres, supported by the original one specialist referral clinic at Zomba Central Hospital (ZCH). The success of our program in increasing ART coverage and decentralisation of care led to new challenges.  The burgeoning load of ART patients at rural health centres placed an ever-increasing burden on health care staff, already reeling from severe staff shortages and existing heavy non-HIV primary care patient burden (including malaria, diarrheal disease, respiratory infections, maternal and child care). Failure to successfully integrate the ever-increasing demands of HIV/AIDS care with existing primary care in hospitals and health centres threatened to either reduce access to and the quality of HIV care, displace primary care, or both. There was a need for better integration at the community level of HIV prevention and treatment with other primary care priorities such as combined HIV/TB treatment, STI management, malaria and maternal and child health services.

Dignitas went on to develop, implement and evaluate a 2-year knowledge translation project that will facilitate the integration of HIV/AIDS and TB care with primary care through activities that build sustainable capacity in the Zomba District health system.

This intervention package, which has the working title STAT-PALM+ (Simplified Tools and Training – Practical Approach to Lung health plus HIV/AIDS in Malawi), is a Malawian adaptation of PALSA PLUS (Practical Approach to Lung Health and HIV/AIDS in South Africa). An international and inter-professional research team was established including the developers of the original PALSA PLUS guideline and training program. Malawi-based team members included key national and district level MoH personnel, representatives of Malawian professional associations, and representatives of an international non-governmental organization. The PALSA PLUS guideline was used as starting point, but was heavily revised based on the most current versions of Malawi national disease-specific guidelines. A content review was carried out, with some primary care conditions of relevance to Malawi (e.g. malaria) and key symptom-based management pages (e.g. approach to fever) added. Advice and input on drafts was sought from local clinical experts and practicing clinicians, including middle-cadre personnel, as well as a wide array of Malawi Ministry of Health personnel and representatives of Malawian professional associations. The intervention targets middle-cadre HCWs (clinical officers, nurses, and medical assistants) and is currently being piloted in a cluster-randomised trial in health centres in the Zomba District.

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