title: From PALSA PLUS to PALM PLUS: adapting and developing a South African guideline and training intervention to better integrate HIV/AIDS care with primary care in rural health centers in Malawi.
abstract: BACKGROUND
  Only about one-third of eligible HIV/AIDS patients receive anti-retroviral treatment (ART). Decentralizing treatment is crucial to wider and more equitable access, but key obstacles are a shortage of trained healthcare workers (HCW) and challenges integrating HIV/AIDS care with other primary care. This report describes the development of a guideline and training program (PALM PLUS) designed to integrate HIV/AIDS care with other primary care in Malawi. PALM PLUS was adapted from PALSA PLUS, developed in South Africa, and targets middle-cadre HCWs (clinical officers, nurses, and medical assistants). We adapted it to align with Malawi's national treatment protocols, more varied healthcare workforce, and weaker health system infrastructure.
  
  
  METHODS
  The international research team included the developers of the PALSA PLUS program, key Malawi-based team members and personnel from national and district level Ministry of Health (MoH), professional associations, and an international non-governmental organization. The PALSA PLUS guideline was extensively revised based on Malawi national disease-specific guidelines. Advice and input was sought from local clinical experts, including middle-cadre personnel, as well as Malawi MoH personnel and representatives of Malawian professional associations.
  
  
  RESULTS
  An integrated guideline adapted to Malawian protocols for adults with respiratory conditions, HIV/AIDS, tuberculosis, and other primary care conditions was developed. The training program was adapted to Malawi's health system and district-level supervision structure. PALM PLUS is currently being piloted in a cluster-randomized trial in health centers in Malawi (ISRCTN47805230).
  
  
  CONCLUSIONS
  The PALM PLUS guideline and training intervention targets primary care middle-cadre HCWs with the objective of improving HCW satisfaction and retention, and the quality of patient care. Successful adaptations are feasible, even across health systems as different as those of South Africa and Malawi.
authors.affiliation: Dignitas International, 2 Adelaide Street West, Suite 200, Toronto, M5H 1L6, Canada. mjs@ices.on.ca
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Schull
authors.forename: Ruth
authors.initials: R
authors.lastname: Cornick
authors.forename: Sandy
authors.initials: S
authors.lastname: Thompson
authors.forename: Gill
authors.initials: G
authors.lastname: Faris
authors.forename: Lara
authors.initials: L
authors.lastname: Fairall
authors.forename: Barry
authors.initials: B
authors.lastname: Burciul
authors.forename: Sumeet
authors.initials: S
authors.lastname: Sodhi
authors.forename: Beverley
authors.initials: B
authors.lastname: Draper
authors.forename: Martias
authors.initials: M
authors.lastname: Joshua
authors.forename: Martha
authors.initials: M
authors.lastname: Mondiwa
authors.forename: Hastings
authors.initials: H
authors.lastname: Banda
authors.forename: Damson
authors.initials: D
authors.lastname: Kathyola
authors.forename: Eric
authors.initials: E
authors.lastname: Bateman
authors.forename: Merrick
authors.initials: M
authors.lastname: Zwarenstein
mesh_terms: D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D003695:Delivery of Health Care; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D004509:Education, Nursing, Continuing / Q000379:methods*; D015658:HIV Infections / Q000188:drug therapy*; D006291:Health Policy; D006297:Health Services Accessibility; D006801:Humans; D008295:Malawi; D010347:Patient Care Planning; D017410:Practice Guidelines as Topic; D011320:Primary Health Care; D018794:Problem-Based Learning; D011637:Public Health Nursing / Q000193:education*; D012423:Rural Health; D019035:Rural Health Services; D012424:Rural Population
chemical_list: D044966:Anti-Retroviral Agents