Scaling up of highly active antiretroviral therapy in a rural district of Malawi: an effectiveness assessment.

BACKGROUND: The recording of outcomes from large-scale, simplified HAART (highly active antiretroviral therapy) programmes in sub-Saharan Africa is critical. We aimed to assess the effectiveness of such a programme held by Médecins Sans Frontières (MSF) in the Chiradzulu district, Malawi. METHODS: We scaled up and simplified HAART in this programme since August, 2002. We analysed survival indicators, CD4 count evolution, virological response, and adherence to treatment. We included adults who all started HAART 6 months or more before the analysis. HIV-1 RNA plasma viral load and self-reported adherence were assessed on a subsample of patients, and antiretroviral resistance mutations were analysed in plasma with viral loads greater than 1000 copies per mL. Analysis was by intention to treat. FINDINGS: Of the 1308 patients who were eligible, 827 (64%) were female, the median age was 34.9 years (IQR 29.9-41.0), and 1023 (78%) received d4T/3TC/NVP (stavudine, lamivudine, and nevirapine) as a fixed-dose combination. At baseline, 1266 individuals (97%) were HAART-naive, 357 (27%) were at WHO stage IV, 311 (33%) had a body-mass index of less than 18.5 kg/m2, and 208 (21%) had a CD4 count lower than 50 cells per muL. At follow-up (median 8.3 months, IQR 5.5-13.1), 967 (74%) were still on HAART, 243 (19%) had died, 91 (7%) were lost to follow-up, and seven (0.5%) discontinued treatment. Low body-mass index, WHO stage IV, male sex, and baseline CD4 count lower than 50 cells per muL were independent determinants of death in the first 6 months. At 12 months, the probability of individuals still in care was 0.76 (95% CI 0.73-0.78) and the median CD4 gain was 165 (IQR 67-259) cells per muL. In the cross-sectional survey (n=398), 334 (84%) had a viral load of less than 400 copies per mL. Of several indicators measuring adherence, self-reported poor adherence (<80%) in the past 4 days was the best predictor of detectable viral load (odds ratio 5.4, 95% CI 1.9-15.6). INTERPRETATION: These data show that large numbers of people can rapidly benefit from antiretroviral therapy in rural resource-poor settings and strongly supports the implementation of such large-scale simplified programmes in Africa

Exploring the relationship between privatisation of health care and infant mortality in Africa

The introduction of user fee system in the government health facilities of most Sub-Saharan African countries (SSA), shifted part of the burden of financing health care onto the community, raising concerns about its relation to the health outcome of the infants and children. To explore whether user fees have no relation to the reduction in under five mortality rate in SSA. We took user fees as a proxy measure for Privatization in the health sector and under five mortality rate (U5MR) as a proxy measure for the infant and child mortality rate. The exploratory study involved thirty-seven SSA countries who had implemented some form of user fees systems by 1995. We analyzed by regression cross-sectional data of the study variables, in addition to studying literature on the subject. Out-of pocket payment has a relation to the reduction of U5MR in SSA. The null hypothesis rejected at conventional level of 0.05, (p= 0.233) and CI (-1.136 to 0.288). A review of the literature further emphasizes this reduction, elaborating on how user fees do influence the health seeking behaviors of the families of these children. We can to an extent attribute the reduction in the health outcome of the infants and children of Sub-Saharan Africa to out-of-pocket payment, bearing in mind that user fees as a health policy can be seen in this instance as a "input", to a means to an end. As a health policy, user fee should be implemented with specific regulations, and supplemented with other forms of health care financing, to boost government revenue and development of the health care delivery systems