Is HIV treatment fairly distributed in Malawi?

Malawi extended its free HIV drug treatment through its public health service to reach 17,000 patients by March 2005. But who is getting treatment? Is drug distribution fair? Research by the Ministry of Health shows steady progress but a need to improve access for children, pregnant women and patients with tuberculosis (TB).

An estimated 900,000 adultsand children in Malawi are living with HIV and AIDS. Up to 170,000 need anti-retroviraltherapy (ART) immediately. By January 2005, 34 public health facilities weredelivering ART free of charge, using the first line combination of stavudine, lamivudine and nevirapine. But there are worries that users may not berepresentative of the population in need of treatment. To study this, researcherslooked at patient cards and registers for patients who started on ART in thelast three months of 2004 (3,261 patients) and the first three months of 2005(4,530 patients). They found that of these:

• About 40 percent aremale.
• Some 95 percent areat least 13 years old.
• The women are ingeneral 10 years younger than the men.
• Up to 90 percentstarted ART because of a clinical assessment of World Health Organizationstages III or IV of HIV disease; the rest due to a low CD4 cell counts.
• Eleven to 15percent have TB.
• Only 29 pregnantwomen were part of programmes to prevent mother-to-child transmission of HIV.
• Around 56 to 62percent are subsistence farmers, housewives or in small-scale businesses suchas being a market vendor or selling fish.
• Six percent andfour percent of patients, respectively, are teachers and health care workers.

These results show that thecharacteristics of patients receiving ART reflect those of adults with HIV interms of gender, age and occupation. However, 10 to 15 percent rather than fivepercent should be children and many more pregnant women require ART. Inaddition, only 1,053 of the predicted 10,000 TB patients who needed ART joinedthe programme in this six month period. The rural population may also beunderserved. Improving access for these groups requires:

• new technicalrecommendations to simplify the diagnosis and management of HIV in children,especially infants
• moreuser-friendly paediatric drug formulations
• prioritising thelimited number of free CD4 tests for patients in stage II or pregnant women instage I of HIV
• better access toHIV testing for TB patients
• addressing druginteraction between TB and HIV treatments
• resolving the tension between delivery of ART largely throughhospitals and of TB treatment through health centres.