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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

Michael J Schull1234*, Ruth Cornick5, Sandy Thompson1, Gill Faris5, Lara Fairall5, Barry Burciul1, Sumeet Sodhi1, Beverley Draper5, Martias Joshua67, Martha Mondiwa8, Hastings Banda9, Damson Kathyola6, Eric Bateman5 and Merrick Zwarenstein134

Author Affiliations

1 Dignitas International, 2 Adelaide Street West, Suite 200, Toronto, M5H 1L6, Canada

2 Department of Medicine, University of Toronto, 200 Elizabeth Street, Toronto, M5G 2C4, Canada

3 Department of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Suite 425, Toronto, M5T 3M6, Canada

4 Clinical Epidemiology Unit, Sunnybrook Health Sciences Center, 2075 Bayview Ave, Toronto, M4N 3M5 Canada

5 Knowledge Translation Unit, University of Cape Town Lung Institute, University of Cape Town, PO Box 34560, Groote Schuur 7937, South Africa

6 Ministry of Health Malawi, POB 3, Lilongwe, Malawi

7 Zomba Central Hospital, Kamuzu Highway, Zomba, Malawi

8 Nurses and Midwives Council of Malawi, POB 30361, Lilongwe, Malawi

9 Research for Equity and Community Health (REACH) Trust, POB 1597, Lilongwe, Malawi

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Implementation Science 2011, 6:82  doi:10.1186/1748-5908-6-82

Published: 26 July 2011



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.


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.


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).


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.