Article Text

Introduction and evaluation of a ‘pre-ART care’ service in Swaziland: an operational research study
  1. David Burtle1,
  2. William Welfare2,
  3. Susan Elden2,
  4. Canaan Mamvura2,
  5. Joris Vandelanotte3,
  6. Emily Petherick4,
  7. John Walley1,
  8. John Wright4
  1. 1Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
  2. 2Good Shepherd Hospital, Siteki, Swaziland
  3. 3ICAP Swaziland, Mbabane, Swaziland
  4. 4Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
  1. Correspondence to William Swithun Welfare; wwelfare{at}


Objective To implement and evaluate a formal pre-antiretroviral therapy (ART) care service at a district hospital in Swaziland.

Design Operational research.

Setting District hospital in Southern Africa.

Participants 1171 patients with a previous diagnosis of HIV. A baseline patient group consisted of the first 200 patients using the service. Two follow-up groups were defined: group 1 was all patients recruited from April to June 2009 and group 2 was 200 patients recruited in February 2010.

Intervention Introduction of pre-ART care—a package of interventions, including counselling; regular review; clinical staging; timely initiation of ART; social and psychological support; and prevention and management of opportunistic infections, such as tuberculosis.

Primary and secondary outcome measures Proportion of patients assessed for ART eligibility, proportion of eligible patients who were started on ART and proportion receiving defined evidence-based interventions (including prophylactic co-trimoxazole and tuberculosis screening).

Results Following the implementation of the pre-ART service, the proportion of patients receiving defined interventions increased; the proportion of patient being assessed for ART eligibility significantly increased (baseline: 59%, group 1: 64%, group 2: 76%; p=0.001); the proportion of ART-eligible patients starting treatment increased (baseline: 53%, group 1: 81%, group: 2, 81%; p<0.001) and the median time between patients being declared eligible for ART and initiation of treatment significantly decreased (baseline: 61 days, group 1: 39 days, group 2: 14 days; p<0.001).

Conclusions This intervention was part of a shift in the model of care from a fragmented acute care model to a more comprehensive service. The introduction of structured pre-ART was associated with significant improvements in the assessment, management and timeliness of initiation of treatment for patients with HIV.

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  • DB and WSW contributed equally to this work.

  • To cite: Burtle D, Welfare W, Elden S, et al. Introduction and evaluation of a ‘pre-ART care’ service in Swaziland: an operational research study. BMJ Open 2012;2:e000195. doi:10.1136/bmjopen-2011-000195

  • Contributors SE, CM, JV, JWr and JWa devised and implemented the intervention. SE and CM undertook data collection and initial evaluation. DB, WSW, JWa, JWr devised the evaluation. DB and WSW undertook the evaluation and initial analysis. EP undertook the statistical analysis. DB, WSW and EP prepared the manuscript. All contributed to revising the manuscript.

  • Funding This document is an output from a project funded by UK Aid from the UK Department for International Development (DFID) for the benefit of developing countries. However, the views expressed and information contained in it are not necessarily those of or endorsed by DFID, which can accept no responsibility for such views or information or for any reliance placed on them.

  • Competing interests None.

  • Ethics approval Ethics approval was provided by Swaziland Ministry of Health Scientific and Ethical Committee and University of Leeds.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Anonymised data on request after review of request by corresponding author (wwelfare{at}

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