Main text
Background
Number | (%) | |
---|---|---|
Total ART clinic registrations (these include first-time ART initiations, re-initiations after treatment interruption and patients transferring from one site to another) | 1,025,754 | (100) |
Registration type: | ||
First time ART initiations ART re-initiations after treatment interruption ART transfers from one clinic to another | 820,367 11,520 193,867 | (80) (1) (19) |
Gender at ART initiation: | ||
Male Female Non-pregnant Pregnant | 369,284 656,470 536,145 120,325 | (36) (64) (82) (18) |
Age at ART initiation: | ||
Adults aged 15 years and above Children 0–14 years | 936,603 89,151 | (91) (9) |
Reason for starting ART: | ||
Presumed severe HIV disease Confirmed HIV infection—WHO Stage 1 or 2 Confirmed HIV infection—WHO Stage 3 Confirmed HIV infection—WHO Stage 4 Unknown | 3520 447,066 467,590 100,379 7199 | (<1) (43) (47) (10) (<1) |
Primary outcomes by 30 June 2015:a | ||
Alive on ART Lost to follow up Stopped ART Died | 565,105 174,554 3366 77,342 | (69) (21) (<1) (10) |
Total died: | ||
Died month 1 Died month 2 Died month 3 Died month 4 and later | 19,087 11,998 7075 39,182 | (25) (16) (9) (50) |
The thinking behind Malawi’s First ART Guidelines
WHO 2003 ART Guidelines | Malawi 2003 ART Guidelines | |
---|---|---|
When to start ART | Stage 4, Stage 3, Stage 2 with CD4 count or Total Lymphocyte count below threshold, Stage 1 with CD4 count below threshold | Followed WHO Guidance |
What to start | Choice of 4 first-line ART regimens based on d4T/AZT, 3TC or EFV/NVP | One first-line ART regimen only (d4T + 3TC + NVP) with alternatives if toxicity occurred |
How to start ART | No specific advice | Advice about staging patients, group counselling and individual counselling and how to manage the first 2 weeks on half-dose nevirapine |
Clinical and laboratory monitoring | Recommended tiered laboratory capabilities based on level of health care facility | Emphasised clinical monitoring only due to poor country-wide laboratory infrastructure |
Adherence to medication | General advice about adherence and monitoring | Specific advice around pill counting |
Children | Advice about dosing—recommendations for not splitting fixed-dose tablets | Advice about splitting first-line fixed-dose ART according to weight |
HIV-Tuberculosis | Advice based on CD4 count or consideration of ART based on clinical judgement | Advice about starting all HIV-infected TB patients on ART in continuation phase with isoniazid and ethambutol |
Standardised treatment outcomes on life-long ART | No advice given | Standardised treatment outcomes defined |
Programmatic monitoring, recording and reporting | No advice given | Advice about patient identity cards, patient treatment master cards, patient ART registers and patient cohort analysis |
Supervision | No advice given | Advice about quarterly supervision of all ART clinics including drug security checks |
ARV drug procurement and distribution | No advice given | Advice about “start packs” and “continuation packs” and how to forecast drug needs |
Scaling up ART in Malawi
Factors important for success
Challenges
Using operational research to learn while doing
Cotrimoxazole preventive therapy
Task shifting and decentralisation
Electronic medical record systems
Malawi and Option B+
Advantage | Explanation |
---|---|
Simple to implement | One tablet a day of TDF + 3TC + EFV for the woman with NVP infant prophylaxis for 6 weeks. Reinforces the nationwide message that ART is taken for life; procurement and distribution needs for the country made easier compared with having Option A or Option B. |
Reduced vertical transmission from mother to child | For current pregnancy ART offers protection from time of administration and is continued in breast feeding period. For future pregnancies, ART offers protection from time of conception. |
Avoids stop-start ART | Interrupted ART has risks for increased morbidity and mortality. |
Improved maternal health and survival | Post-partum women in Zimbabwe with CD4 count > 350 cells/mm3 have an elevated risk of death six times higher than non-infected women [40]. |
Reduced sexual transmission of HIV to discordant couples | HIV-infected persons on ART have significantly reduced risk of HIV transmission through sexual intercourse to non-infected partners even at high CD4 cell counts [41]. |
Reduced risk of tuberculosis | ART reduces the risk of tuberculosis in people living with HIV, even at high CD4 cell counts [42]. |
Treats hepatitis B infection | Tenofovir and lamivudine are active against hepatitis B virus, and about 15 % of people living with HIV in Malawi are also infected with hepatitis B. |
Conclusion
Policy | Year of implementation in Malawi | Year recommended by WHO | Supporting evidence from randomized trials or systematic reviews |
---|---|---|---|
Lifelong cotrimoxazole preventive therapy | 2006 | 2006 WHO Cotrimoxazole Guidelines [28] | Reference [51] |
Task shifting for the delivery of ART | 2003 | 2008 WHO Guidelines for task shifting [33] | |
Decentralization of ART delivery | 2003 | 2013 WHO Consolidated Guidelines [47] | |
PMTCT Option B+ | 2011 | 2012 WHO Programmatic Update [46] | None |
2013 WHO Consolidated Guidelines [47] |