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The Effects of Health System Frailties on the Projected Impact of the HIV and TB Programmes in Malawi
15 Pages Posted: 17 Jul 2023
More...Abstract
Malawi is steadily advancing towards the UNAIDS and WHO End TB programme targets, with the joint goals of eliminating AIDS and TB as public health threats. Here we examine the projected impact of reaching these targets and the potential mitigating effects of consumables constraints.
Methods: The Thanzi la Onse model is an individual-based multi-disease simulation model which represents HIV and TB together, alongside other diseases, and gates access to essential medicines according to empirical estimates of availability. The model integrates dynamic disease modelling with health system engagement behaviour, health system usage and capabilities (personnel and consumables). HIV and TB programme scale-up are projected until 2035.
Findings: With uninterrupted supplies of key medicines, HIV and TB incidence falls to 22 and 60 cases /100,000 person-years respectively by 2035 (from 190 and 149 cases /100,000 person-years in 2020) and approximately 4·04 million DALYs could be averted by meeting the current UNAIDS and WHO targets. However, with current stockout levels, programme scale-up has limited impact on incidence and mortality. 10-15% of TB patients would experience >10-week delays for treatment and approximately 115,000 additional deaths (67,000 AIDS and 48,000 TB deaths) could occur due to bottlenecks in supply chains of essential medicines.
Interpretation: Projections of HIV and TB scale-up that ignore existing frailties in the healthcare system (e.g. consumables non-availability) risk over-estimating the possible health impact and under-estimating the required health system resources. Target-focussed programme scale-up, without synchronised health system strengthening, could have negative consequences by increasing demand on a highly constrained system.
Funding: This project is funded by The Wellcome Trust (223120/Z/21/Z). The initial development of the model was completed with support by the UK Research and Innovation as part of the Global Challenges Research Fund, (MR/P028004/1). TBH, TM, MM and BS acknowledge funding from the MRC Centre for Global Infectious Disease Analysis (reference MR/R015600/1), jointly funded by the UK Medical Research Council (MRC) and the UK Foreign, Commonwealth & Development Office (FCDO), under the MRC/FCDO Concordat agreement and is also part of the EDCTP2 programme supported by the European Union; and acknowledges funding by Community Jameel.
Declaration of Interest: The authors have no conflicts of interest to declare.
Ethical Approval: This study was approved by the College of Medicine Research Committee (COMREC) in Blantyre, Malawi (protocol number: P.10/19/2820). As this study used secondary anonymised and aggregated data, individual informed consent was not required. Permission on using these data was obtained from Ministry of Health and Population, Malawi.
Keywords: HIV, TB, health system, consumables constraints, programme scale-up, simulation modelling
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