Background: Although Malawi is on track to achieve the UNAIDS 90-90-90 HIV targets, there is sub-optimal switching of patients to second-line antiretroviral treatment (ART) with first-line treatment failure. Challenges include unavailability of viral load (VL) results and low levels of knowledge on provision of second-line ART. We assessed in-service knowledge of different cadres of first-line ART providers on the management of second-line ART patients.
Methods: In 2016, 754 first-line ART providers (medical doctors, clinical officers, medical assistants, registered nurses, nurse-midwife technicians and community nurses) from 26 districts in Malawi were trained on second-line ART provision. After the training, a certification exam was administered to assess providers'' ability to: 1) identify second-line regimens; 2) choose appropriate second-line ART based on first-line treatment failure scenarios; 3) interpret VL results; and 4) prescribe correct dosages for second-line ART. ART providers that scored ≥80% were certified to prescribe second-line regimens. Proportions and chi-squared tests were used to analyze results of the exam by cadre and district.
Results: Of the 754 ART providers assessed; 21(3%) were medical doctors, 241(32%) were clinical officers, 147(20%) were medical assistants, 44(6%) were registered nurses, 260(34%) were nurse-midwife technicians, and 41(5%) were community nurses. Overall, 290 (38.46%) were eligible to prescribe second-line regimens, with significant differences by both cadre and district (p<0.001). Specifically, a higher proportion of medical doctors, clinical officers, and registered nurses (66.67%, 56.43%, and 36.64%, respectively) were eligible to prescribe when compared with medical assistants (24.49%), and nurse-midwife technicians (28.08%). Among all cadres, providers performed best in identifying (n=518, 68.70%) and correctly dosing (n= 588, 77.98%) second-line ART. Few providers correctly chose second-line ART regimens (n=71, 9.42%) or interpreted VL results (n=67, 8.89%). Ability to both identify and correctly choose second-line ART differed significantly by cadre and district, while ability to correctly dose varied by district (P<0.001) and ability to interpret VL varied by cadre (p<0.001).
Conclusions: Overall performance in the second-line ART certification examination was sub-optimal. There is need for strengthening knowledge on second-line ART through intensive trainings. Ensuring workforce capacity for switching to second-line regimens is important to achieving the UNAIDS 90-90-90 goals.

Download the e-Poster