Passing the test: allocating antiretroviral therapy in Malawi

How can expensive antiretroviral therapy be best prioritised in under-resourced health systems? In Malawi, targeting laboratory-based tests that measure the progress of the disease may offer one solution to help target those most in need.

Almost one million people suffer from HIV or AIDS in Malawi. By March 2004, only three percent of Malawians who needed antiretroviral therapy (ART) were receiving it. Plans to increase the number to 80,000 (50 percent of those needing treatment), will need to ensure that the most urgent cases are effectively targeted.

A laboratory test, known as the CD4 test, is often used to decide when someone needs ART treatment. The test is a "proxy" for the state of the body's capacity to defend itself against infections. A CD4 count under a threshold level of 350 cells per unit of measurement (microliter, ul) is considered a low level and the body is less able to defend itself against infections. ART treatment is then considered necessary. However, the CD4 test is expensive and high-tech.

The World Health Organisation recommends that in poor countries ART should be given to everyone who has reached stage III and IV of the disease. Médecins sans Frontières and the Ministry of Health of Malawi carried out a study to find out whether all people in stage III and IV did in fact need ART.

Receiving ART too soon could mean that the body becomes resistant to the drugs and the treatment is no longer effective when the patient most needs it. In addition there is the inconvenience of taking the tablets, of possible side effects, and the need for follow-up visits to the hospital. The study was carried out in Thyolo district, a rural part of southern Malawi, between April 2003 and January 2004. Everyone over the age of 13, who attended the district hospital with AIDS stage III or stage IV, was included in the study.

The study found that out of the 401 people studied:

• Seventy-four percent currently had an active disease associated with HIV/AIDS, whilst the other 26 percent came to the hospital for a routine follow-up visit or with other health problems.
• Thirty-two percent were malnourished, 46 percent were below what is expected to be a normal, while 22 percent were rather plump or obese (a high Body Mass Index (BMI).
• Nine percent had a CD4 count of more than 350 cells per microliter and therefore did not require ART at that time.
• The patients with a high CD4 count were more likely to be plump or overweight and did not have an active disease associated with HIV/AIDS.

The study recommends that, while it is not possible to offer everybody CD4 testing:

• patients with a high BMI and those with no apparent active disease associated with HIV/AIDS should have the CD4 test, as a considerable proportion of these subgroups may not yet require ART.
• Routinely screening for such patients in clinics would help target the CD4 test and save resources both in terms of CD4 tests and ART.
• Targeting CD4 testing would also mean smaller numbers of people would be required to undergo CD4 testing and this opens the possibility of using less costly, and less sophisticated instruments for CD4 testing in resource-limited settings.

While targeted CD4 testing may not identify all those with high CD4 counts, it does prevent a considerable number of people from receiving early ART treatment thus saving unnecessary costs associated with ART. In Malawi, the saving could be as much as two million US dollars per year. 

Source(s):
‘Targeting CD4 testing to a clinical subgroup of patients could limit unnecessary CD4 measurements, premature antiretroviral treatment and costs in Thyolo District, Malawi’, Transactions of the Royal Society of Tropical Medicine and Hygiene 100(1): 24-31, Rony Zachariah et al., 2005
HINARI subscribers can access the full-text article here. Full document.

Funded by: Médecins sans Frontières

id21 Research Highlight: 16 March 2006

Further Information:
Rony Zachariah
Médecins sans Frontières
Medical Department (Operational Research HIV-TB)
Brussels Operational Centre
94 Rue Dupre
Brussels
Belgium

Tel: +352 332515
Fax: +352 335133
Contact the contributor: zachariah@internet.lu

Médecins sans Frontières

Anthony D. Harries
Ministry of Health HIV Care Unit
Malawi Country Office
Arwa House, 3rd Floor
PO Box 30455
Lilongwe 3
Malawi

Tel: +265 1 795054
Fax: +265 8352613
Contact the contributor: adharries@malawi.net

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'Battling the bugs – cutting death rates among HIV-positive TB patients'

'Predicting health care needs and costs at HIV/AIDS clinics in India'

'Malawi: why HIV raises the risk of malaria during pregnancy'

'HIV/AIDS awareness and treatment: effective at fighting the HIV epidemic in rural Uganda?'

'Transmitting through time: monitoring HIV transmission rates in rural Tanzania'

See id21's collection of links relevant to HIV/AIDS.