Background: The provision of three-month antiretroviral (ARV) refills, or multi-month scripting (MMS), for stable HIV patients on antiretroviral therapy (ART) can increase service efficiency and decrease congestion. Since 2008, Malawi has offered MMS to patients that are 18 years or older, have been on ART at least six months, are on first-line ART, have no adverse drug reactions or opportunistic infections, have a viral load less than 1000 copies/mL, and have good adherence according to pill counts. We assessed the extent to which patients are accurately differentiated as eligible or ineligible for MMS and explored potential causes of inaccurate patient differentiation.
Methods: Data were collected from 30 purposefully selected ART facilities in 2016. Participation and eligibility for MMS were determined based on 75,364 patient clinical records, which were analyzed using Stata version 13. Results were weighted and clustered by facility. The reasons for inaccurate patient differentiation were explored using structured surveys with 136 health workers and 32 qualitative interviews with clinic management. Interviews were audio recorded, transcribed and thematically coded.
Results: A majority of patients (86.4%, 95% confidence interval [CI] 84.0-88.6) were eligible and 68.7% of patients (95% CI 62.5-74.6) were receiving MMS. Among patients eligible for MMS, 72.9% (95% CI 66.3-78.6) received MMS. However, 42.3% (95% CI 33.1-52.0) of ineligible patients (amounting to 5.7% of all patients) also received MMS. Results were similar based on sensitivity analyses using different eligibility criteria scenarios, but variation in the application of criteria existed across facilities. Among ineligible patients receiving MMS, 77% had viral load greater than 1000 copies/mL, and 39% had been on ART less than six months. Inaccurate patient differentiation was suggested to result from lack of health worker knowledge of the criteria for MMS, patient requests, health worker attempts to reduce workload, and perceived challenges with low stocks of medications.
Conclusions: MMS is being widely implemented in Malawi, but patient differentiation in many facilities is not happening according to the agreed upon definition of eligibility. Simplification of guidance, improvements in health worker mentorship, patient counseling, and alignment of patient record forms against eligibility criteria would improve patient differentiation in Malawi.