Access to essential medicines: Antiretroviral therapy in Malawi 

by Justin Sherwin

In December ’06- February ’07, during the Australian summer, I worked in a volunteer capacity in Ghana, Kenya and Malawi. Following my time in Ghana and Kenya where I spent the majority of my time in blindness prevention projects, I travelled to Malawi and was based in Nkhoma. Nkhoma features a mission hospital founded by the Dutch Reformed Church. It is situated 50km to the east of the capital Lilongwe. Serving a population of over 33000 in the surrounding 10 Kilometres, it also has a referral population of over 60,000. In addition to providing general medical, surgical, obstetrics/gynaecology and paediatric services, the hospital also offers comprehensive, but not exhaustive, HIV/AIDS services.

In many of the regions which I visited, the principle of diagnosis and treatment was to ‘do your best in spite of inadequate conditions and equipment/ medicines.’ Heartbreaking stories were commonplace, most of which could have been prevented with adequate stocks of pharmaceuticals. Witnessing patients dying of pulmonary emboli because stocks of heparin were depleted or suffering from severe post— operative wound infections and systemic sepsis because the only antibiotic available at the time was PR metronidazole was difficult to comprehend in its entirety. Undoubtedly, these episodes should have been prevented. Yet, simple medicines which are easily taken for granted in developed countries, are in widespread need throughout the developed world.

HIV in Malawi

During my stay in Malawi, I spent time within the HIV/AIDS unit undertaking clinical and research roles. The current population of Malawi is approximately 12 million. In 2003 the HIV prevalence in adults (15-49 years) of population that is infected with HIV was estimated to be14.4%., with 58% being women. There are also 70,000 children infected. The annual deaths due to HIV/AIDS are estimated at 80,000. Thus, these disturbing rates of HIV infection need urgent figures intervention. Many organisations, government and non-government (NGO), are currently working to achieve better treatment for those affected and improved preventative strategies for those at risk. However, more funding is needed to ensure the grow, development and maintenance of such initiatives.

Antiretroviral therapy (ART) services at Nkhoma

During my time in Nkhoma I managed to assist with an audit of the hospital VCT (voluntary counselling and testing for HIV/AIDS) services. Of the 1703 patients tested at Nkhoma in 2005, 451 returned a positive serological diagnosis.

Reasons for commencing ART in Malawi are the following; having a World Health Organisation (WHO) stage III (symptomatic HIV infection) or WHO IV (AIDS) disease status or having a CD4 count < 200. Unfortunately the latter test is out of the reach of most budgets, because testing costs roughly $10 US, and most earn far less than that per day. Furthermore, patients must travel to Lilongwe to undertake the test. Of those eligible for ART, 281 patients (67.22%) were stage III, 127 patients (30.38%) were stage IV and 10 (2.39%) had a CD4 count < 200. 

Starting in late 2004, 418 patients had commenced ART at Nkhoma as of December 31st 2006. 36% of patients were male, 64% female and 5% were under the age of 5. The majority of patients on ART were farmers (71%). Coexistent Tuberculosis infection, pulmonary or extra-pulmonary, and being pregnant whilst HIV+ve are further indications for commencing ART in Malawi.

HIV positive patients in Malawi receive their ART at a time in which they are already very ill with disease. If ART is commenced at stage I or II infection, improved outcomes can result, including increased life expectancy, increased CD4 counts and decreased viral loads. They also have been shown to decrease passage of the virus to (newly born) children of infected mothers. Yet, due to financial constraints and insufficient foreign aid, patients receive their ART often at a time when it is too late to make a difference to patients’ health and well being. 337 of the 418 who commenced ART are still taking ART to the Malawi Ministry of Health (MOH) recommended schedule, 36 have died, and only 8 have reported significant sideeffects of therapy.

HIV +VE individuals require more medicines than merely ART. Treatment of opportunistic infections is a veritable challenge, especially considering the often inadequate diagnostic facilities present in developing regions. Improved access to antibiotics (as well as antivirals, anti-TB, antifungals etc) will ensure that affected patients can have decreased morbidity associated with treatable infections. Although the HIV virus is not amenable to curative therapy at present, patients deserve the best treatment available. During my stay at Nkhoma hospital, I gained a valuable insight into tragedy of HIV in Sub-Saharan Africa and the uphill battle that the region faces in order to effectively combat the crippling situation. Generations will be wiped out unless urgent assistance is taken immediately. Thus, foreign aid, with the assistance of drug company financial support should assist in the prevention and treatment of this cruel and devastating disease. More funding and improved access to vital medicines is required to ensure the ongoing running of the VCT and ART programs at Nkhoma and other regions of Malawi and Sub-Saharan Africa. This would help to ensure that patients receive ART at a time which would turn HIV into a ‘chronic disease’ as opposed to a death sentence.