Community support is associated with better antiretroviral therapy outcomes in Malawi

Since 1999, Médécins Sans Frontières (MSF) has been developing an AIDS programme with the ministry of health in Thyolo, a rural district of southern Malawi. The programme includes community support.  In 2003, Thyolo introduced antiretroviral therapy (ART) for some individuals. Has the presence of community support influenced ART outcomes?

Between 2003 and2005, researchers led by Médécins Sans Frontières (MSF) reviewed ART outcomesin the areas of Thyolo where community support was available and compared themwith areas which lacked such support. At the same time, three of the seventraditional authorities in Thyolo were providing community support through volunteers,community nurses and trained family carers.

The basic packageof care included home management of opportunistic infections (diseasesassociated with HIV and AIDS), early referral to medical help for patients withpossible drug reactions and risk signs, counselling on drug adherence, supportto family carers, and tracing defaulters (those who had not attended follow-upappointments for three months or more). Further activities includedinformation, education and communication; nutritional support; and vocationaltraining for AIDS orphans.

Between April 2003and December 2004, there were 1,634 HIV-positive people involved in the studywho were on ART. Of these, 55 percent lived in areas offering community supportwhile 45 percent were from areas without such support. The researchers foundthat the risk of death, defaulting or stopping ART were all significantly lessfor those offered community support. Results showed that:

• ninety-six percent of those who receivedcommunity support were alive and continuing ART at the end of the study,compared with 76 percent of those who did not receive community support
• the death rate was 3.5 percent for thosewho received community support, compared with 15.5 percent for those whodid not
• the percentage of defaulters was 0.1 forthose receiving community support and 5.2 percent for those without support
• only 0.8 percent of those who hadcommunity support stopped ART, compared with 3.3 percent of those withoutcommunity support.

The researchers concludethat a decentralised community network of support leads to much lower deathrates and better overall outcomes for ART. They note that in a country likeMalawi with high HIV prevalence (14 percent of those aged 15-49) and limitedresources, health workers are reluctant to take on the burden of community-basedoutreach work. They argue that:

• HIV and AIDS are chronic lifelongconditions whose treatment and care, including ART, must be continuous andongoing. The community can play an important role in this regard.
• local communities are a largelyunexploited resource that could contribute significantly to ART outcomeson a national scale
• communities are not an unlimitedresource and will require support
• policymakers should think of ways tosustain community resources and identify the parts of the community that willneed further support
• policymakers need to make sure thatthey do not simply pass on to communities those activities that should bethe responsibility of the public services or other partners.