Abstract:
Background: In low-income countries, only about a third of Human Immunodeficiency Virus/Acquired Immune
Deficiency Syndrome (HIV/AIDS) patients eligible for anti-retroviral treatment currently receive it. Providing
decentralized treatment close to where patients live is crucial to a faster scale up, however, a key obstacle is
limited health system capacity due to a shortage of trained health-care workers and challenges of integrating HIV/
AIDS care with other primary care services (e.g. tuberculosis, malaria, respiratory conditions). This study will test an
adapted primary care health care worker training and guideline intervention, Practical Approach to Lung Health
and HIV/AIDS Malawi (PALM PLUS), on staff retention and satisfaction, and quality of patient care.
Methods/Design: A cluster-randomized trial design is being used to compare usual care with a standardized
clinical guideline and training intervention, PALM PLUS. The intervention targets middle-cadre health care workers
(nurses, clinical officers, medical assistants) in 30 rural primary care health centres in a single district in Malawi.
PALM PLUS is an integrated, symptom-based and user-friendly guideline consistent with Malawian national
treatment protocols. Training is standardized and based on an educational outreach approach. Trainers will be
front-line peer healthcare workers trained to provide outreach training and support to their fellow front-line
healthcare workers during focused (1-2 hours), intermittent, interactive sessions on-site in health centers. Primary
outcomes are health care worker retention and satisfaction. Secondary outcomes are clinical outcomes measured
at the health centre level for HIV/AIDS, tuberculosis, prevention-of-mother-to-child-transmission of HIV and other
primary care conditions. Effect sizes and 95% confidence intervals for outcomes will be presented. Assessment of
outcomes will occur at 1 year post- implementation.
Discussion: The PALM PLUS trial aims to address a key problem: strengthening middle-cadre health care workers
to support the broader scale up of HIV/AIDS services and their integration into primary care. The trial will test
whether the PALM PLUS intervention improves staff satisfaction and retention, as well as the quality of patient
care, when compared to usual practice.