Can we get more HIV-positive tuberculosis patients on antiretroviral treatment in a rural district of Malawi?
The World Health Organization (WHO) has set a target of treating 3 million people with antiretroviral treatment (ART) by 2005. In sub-Saharan Africa, HIV-positive tuberculosis (TB) patients could significantly contribute to this target. ART (stavudine/lamivudine/nevirapine) was initiated in Thyolo district, Malawi, in April 2003, and all HIV-positive TB patients were considered eligible and offered ART. Despite this, only 44 (13%) of 352 TB patients were eventually started on ART by the end of November 2003. Most TB patients leave hospital after 2 weeks to complete the initial phase of anti-tuberculosis treatment (rifampicin-based) in the community, and ART is offered to HIV-positive TB patients after they have started the continuation phase of treatment (isoniazid/ ethambutol). ART is only offered at hospital, while the majority of TB patients take their continuation phase of anti-tuberculosis treatment from health centres. HIV-positive TB patients therefore find it difficult to access ART. In this paper, we discuss a series of options to increase the uptake of ART among HIV-positive TB patients. The main options are: 1) to hospitalise HIV-positive TB patients with a view to starting ART in the continuation phase in hospital; 2) to decentralise ART delivery so ART can be delivered at health centres; 3) to replace nevirapine with efavirenz so ART can be started earlier in the initial phase of anti-tuberculosis treatment. Decentralisation of ART from hospitals to health centres would greatly improve ART access.
Zachariah
R
R
Medical Department (HIV-TB Operational Research), Brussels Operational Centre, Médecins sans Frontières, Brussels, Belgium. zachariah@internet.lu
Teck
R
R
Ascurra
O
O
Gomani
P
P
Manzi
M
M
Humblet
P
P
Nunn
P
P
Salaniponi
F M L
FM
Harries
A D
AD
D019380:Anti-HIV Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active / Q000379:methods; D000995:Antitubercular Agents / Q000627:therapeutic use; D004359:Drug Therapy, Combination; D004363:Drug Utilization; D006679:HIV Seropositivity / Q000150:complications / Q000188:drug therapy* / Q000453:epidemiology; D006801:Humans; D019259:Lamivudine / Q000627:therapeutic use; D008295:Malawi / Q000453:epidemiology; D009313:National Health Programs / Q000639:trends; D019829:Nevirapine / Q000627:therapeutic use; D015995:Prevalence; D012424:Rural Population; D018119:Stavudine / Q000627:therapeutic use; D014376:Tuberculosis / Q000150:complications / Q000188:drug therapy* / Q000453:epidemiology; D014944:World Health Organization
D019380:Anti-HIV Agents; D000995:Antitubercular Agents; D019259:Lamivudine; D019829:Nevirapine; D018119:Stavudine