AIDS in Malawi – Simplifying ARV Treatment to Save Lives
World AIDS Day 2004 — Field Spotlight
December 1, 2004
For the last three years, Doctors Without Borders/Médecins Sans Frontières (MSF) has been treating people living with HIV/AIDS in the Chiradzulu region of Malawi with antiretroviral (ARV) therapy. By simplifying admission criteria and patient treatment procedures, and working with local health centers to provide follow-up care, MSF has been able to put 2500 new patients on ARVs in a single year.
A recent virological study showed the efficacy of triple therapy in Malawi, where extremely encouraging results are comparable to those obtained in the United States and European countries. But unless new treatments are made available in the future, concerns remain about how long patients will continue to enjoy this new lease of life.
Mother and child group medical facility in Chiradzulu Hospital, Malawi
Photo ©Didier Lefevre
Patient numbers were initially limited by a quota and extremely strict admission criteria. “It was clear,” says the program's manager, Chris Brasher, MD, “that the technological 'case by case' treatment of patients, based on the Western model, could not work in the context of a soaring epidemic in which increasingly large numbers of patients required treatment.”
New procedures were adopted in 2003 when the admission criteria were radically modified: quotas were abandoned, laboratory follow-up tests were reduced or eliminated, and clinical follow-up was simplified. All eligible HIV positive patients, who are WHO stage 3 or stage 4, now start treatment after a simple clinical examination, without laboratory testing. For patients at stage 2 and stage 1, laboratory tests are carried out to ascertain their CD4 count. If the count is lower than 200, the patient is put on treatment. However, in order to limit the risk of failure and the development of drug resistance, an emphasis is placed on patient awareness and access to information before the HIV test and during the initial treatment stages. “Treatment education is fundamental if we want people to appreciate all aspects of the treatment and to ensure strict adherence,” explains Michel Rosenheim, MD, a member of MSF's AIDS Committee.
Simplifying ARV treatment using a generic “3-in-1,” or fixed-dose combination, medicine allows medical staff and nurses with antiretroviral training to monitor patients twice monthly and dispense treatment to clinically “stable” patients. There are currently only 3 doctors for 2500 patients under ARV treatment. “In the future, we would like these nurses to manage the patient inclusion process,” explains Dr. Brasher. “Tasks normally performed by doctors, who are in short supply in Malawi, as in the rest of sub- Saharan Africa, must be delegated to nurses and health workers.”
In addition to the simplification of treatment procedures, a decentralized activity has been set up in ten community health centers offering services similar to those of the hospital in Chiradzulu: testing, education, dispensing ARV drugs, and follow-up. CD4 samples are taken on site before being sent to the hospital. The MSF team and doctor currently visit each center twice monthly. The long-term aim is for nurses who have completed a training course to run the health center autonomously.
Thyolo province, Malawi. Taking an aids patient to the nearest MSF clinic for examination.
Photo ©Gael Turine 2004
The aim of the strategy is to provide treatment for an average 200 new patients every month. Fifty percent receive follow-up in local health centers. “Previously, there had been no virological study to show the efficacy of the treatments used in most of our programs in Africa,” says Dr. Brasher. “Certain indirect indicators, such as body weight, showed that patients were in reasonably good shape. However, we wanted scientific proof that the treatment was effective and that our patients were not falling ill one or two years down the line. We carried out a virological study of 477 sample patients who had been receiving treatment for at least six months. Eighty-five percent of people tested presented a viral load (an indicator that the virus is in the blood) that was undetectable, i.e. below 400 copies (fragments of the virus) per ml, a level comparable to European results.”
Thyolo province, Malawi. Grane K. receiving a visit from an MSF nurse offering home based care.
Photo ©Gael Turine 2004
Although these positive results prove that it is possible to treat HIV infection in Malawi, the challenge of drug resistance has yet to be met. “We now know treatment is still effective after six months, or a year, but what happens after five years? We are certain that these treatments will not be effective in the long-term because the virus is in perpetual mutation. Patients will develop resistance to the drugs, requiring the discovery of new combinations”, adds Dr. Brasher. These risks are currently minimized in Malawi by the use of single-tablet triple therapy and the provision of treatment education. If patients develop resistance to the first-line treatment - which is already the case for some patients - they can still benefit from second-line treatment. But it is far more expensive for second-line medicines because of lack of generic competition. Also, it is impossible to monitor the progress of individual patients, as it would be in Europe or North America. “We risk seeing some of our patients die before they can even benefit from a second-line treatment. And we currently have nothing to offer patients who develop resistance to all the treatments. We are in a position to extend patients' lives,” says Brasher, “but for how long?”