Understanding health systems challenges in providing Advanced HIV Disease (AHD) care in a hub and spoke model: A qualitative analysis to improve AHD care program in Malawi.

Background: Despite tremendous progress in improving antiretroviral therapy (ART) and access to ART, many patients have advanced HIV disease (AHD). AHD patients, whether initiating ART or representing care after disengagement, have an increased risk of morbidity and mortality. EGPAF launched an enhanced care package using a hub and spoke model to optimize AHD care in Malawi. This model improved supplies availability and appropriate linkage to care. We utilize a hub-and-spoke model to share the health facility challenges and recommendations on the AHD package for screening and diagnosis, prophylaxis, treatment, and adherence support. Methods This qualitative study assessed facility-level experiences among healthcare workers (HCWs) and lay cadres (LCs) providing AHD services to patients through the intervention package. The study population included HCWs and LCs supporting HIV care at four intervention sites. Eligible study participants were recruited by trained Research Assistants with support from the health facility's nurse to identify those most involved in supporting AHD patients. A total of 32 in-depth interviews were conducted. Thematic content analysis identified recurrent themes and patterns across participants’ responses. Results While HCWs and LCs stated that most medications are often available in both hub and spoke sites, they reported that sometimes there are limited supplies and equipment to run samples and tests necessary to provide AHD care. More than half of the HCWs stated that AHD training sufficiently prepared them to handle AHD patients at both hubs and spoke levels. The HCWs and LCs reported weaknesses in the patient referral system within the hub-and-spoke model in providing linkage of care to facilities, specifically noting improper referral documentation, incorrect labeling of samples, and inconsistent availability of transportation. While HCWs felt that AHD registers were time-consuming, they remained motivated as they thought they provided better patient services. Conclusions These findings suggest the importance of offering more comprehensive AHD services. The enhanced AHD program addressed weaknesses in service delivery through decentralization and providing services through a hub and spoke model, improved supplies availability, and strengthened linkage to care. Additionally, addressing the recommendations from service providers and patients is essential in improving health and survival among AHD patients.