Is Malawi ready for Test and Treat HIV strategy?

During a recent public debate on HIV and Aids and ARVs aired on Zodiak Broadcasting Station (ZBS), it was revealed that government is planning to introduce the ‘Test and Treat HIV’ strategy, whereby one is put on antiretroviral therapy (ART) right after testing positive.

Dr Frank Chimbwandira, director of the Department of HIV and Aids in the Ministry of Health, says the strategy is currently under discussion.

“We have had some meetings and we are still consulting so that we can come up with a proper proposal and then policy,” he says.

Chimbwandira says if adopted, Malawi will follow France and USA, countries that are already implementing the policy.

“The problem is that if we wait until the viral load is high, chances of keeping the infected person healthy are low. Early treatment keeps one healthier. If the person indulges in unprotected sex, chances of viral transmission are low and again the person lives longer,” says Chimbwandira.

According to both the Malawi’s HIV Prevention Strategy 2009-2013 and the World Health Organisation (WHO), an infected person is supposed to be on ART when the CD4 test that measures the number of T-helper cells which are responsible for body protection from foreign bodies register a fall to between 200 and 350.

WHO says the CD4 test helps to show the level of viral load in one’s blood and when one should begin taking ARVs. However, the authority says low CD4 count does not guarantee that one is sick, but is likely to fall sick.

“It is possible for one to become immuno-deficiency while the viral load is low and the CD4 count is high. This does not warrant that the patient be put on ART, according to the policy we are using now,” says Bridget Salima, an HIV and Aids nurse in Lilongwe.

Currently, the Ministry of Health says over a million people are HIV positive and 505 000 are on ARVs. The National Aids Commission (NAC) website (www.aidsmalawi.org.mw) indicates that around 60 000 new infections are registered annually.

Presently, Chimbwandira says it costs $200 (about K85 800) per year for one to be on ARVs consistently. If the Test and Treat strategy is adopted, government will need about $200 million (K85.8 billion) per year to treat about one million HIV positive Malawians. Currently, government spends about $101 million (K43.3 billion) to treat 505 000 people on ART.

So, can Malawi afford this system?

In July this year, Malawi Network of People Living with HIV and Aids (Manet+) bemoaned an ARVs shortage in Phalombe where patients were being sent back due to lack of ARVs.

But Chimbwandira believes with proper planning and financing, the strategy is feasible.

“Our consultations are focusing on our capacity, costs and managing each patient,” says Chimbwandira.

Steve Iphani, Coalition for Women Living with HIV and Aids (Cowla) programme manager, says the Test and Treat strategy is a good idea, but he is quick to add that Malawi cannot afford it.

He says the most challenging factor is that ART services largely depend on donor funding and to implement such an initiative, Malawi will need to increase its budget allocation to HIV and Aids, which is not easy. He adds that another challenge of the initiative is that it puts on treatment people who are not supposed to be on ART, saying this would increase ARVs default rate.

“Such a strategy has been tried on women living positively by putting them on treatment right away, but recent research shows that retention on ART among the group has dropped by 17 percent because some people see no reason to be on treatment when they are not ill,” explains Iphani.

Martha Kwataine, executive director for Malawi Health Equity Network (Mhen) agrees, saying putting people who are not sick on ART will increase ARVs default rate.

“I am yet to get details of this, but my immediate reaction would be let us not rush into implementing this because despite the advantages, sustainability is a problem. ARVs have side effects and putting positive people on long-time treatment can increase the side effects. The drug needs nutritional support and how will this be addressed?” she asks.