title: Acceptance of anti-retroviral therapy among patients infected with HIV and tuberculosis in rural Malawi is low and associated with cost of transport.
abstract: BACKGROUND
  A study was conducted among newly registered HIV-positive tuberculosis (TB) patients systematically offered anti-retroviral treatment (ART) in a district hospital in rural Malawi in order to a) determine the acceptance of ART b) conduct a geographic mapping of those placed on ART and c) examine the association between "cost of transport" and ART acceptance.
  
  
  RESULTS
  A retrospective cross-sectional analysis was performed on routine program data for the period of February 2003 to July 2004. Standardized registers and patient cards were used to gather data. The place of residence was used to determine road distances to the Thyolo district hospital. Cost of transport from different parts of the district was based on the known cost for public transport to the road-stop closest to the patient's residence. Of 1,290 newly registered TB patients, 1,003(78%) underwent HIV-testing of whom 770 (77%) were HIV-positive. 742 of these individuals (pulmonary TB = 607; extra-pulmonary TB = 135) were considered eligible for ART of whom only 101(13.6%) accepted ART. Cost of transport to the hospital ART site was significantly associated with ART acceptance and there was a linear trend in association between cost and ART acceptance (chi(2) for trend = 25.4, P<0.001). Individuals who had to pay 50 Malawi Kwacha (1 United States Dollar = 100 Malawi Kwacha, MW) or less for a one-way trip to the Thyolo hospital were four times more likely to accept ART than those who had to pay over 100 MW (Adjusted Odds ratio = 4.0, 95% confidence interval: 2.0-8.1, P<0.001).
  
  
  CONCLUSIONS
  ART acceptance among TB patients in a rural district in Malawi is low and associated with cost of transport to the centralized hospital based ART site. Decentralizing the ART offer from the hospital to health centers that are closer to home communities would be an essential step towards reducing the overall cost and burden of travel.
authors.affiliation: Medecins sans Frontieres, Medical Department (Operational Research), Brussels Operational Center, Brussels, Belgium. zachariah@internet.lu
authors.forename: Rony
authors.initials: R
authors.lastname: Zachariah
authors.forename: Anthony David
authors.initials: AD
authors.lastname: Harries
authors.forename: Marcel
authors.initials: M
authors.lastname: Manzi
authors.forename: Patrick
authors.initials: P
authors.lastname: Gomani
authors.forename: Roger
authors.initials: R
authors.lastname: Teck
authors.forename: Mit
authors.initials: M
authors.lastname: Phillips
authors.forename: Peter
authors.initials: P
authors.lastname: Firmenich
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D000995:Antitubercular Agents / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D005260:Female; D015658:HIV Infections / Q000150:complications* / Q000188:drug therapy* / Q000191:economics; D017048:Health Care Costs; D006801:Humans; D008295:Malawi; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care; D012189:Retrospective Studies; D012423:Rural Health; D012424:Rural Population; D014187:Transportation of Patients / Q000191:economics*; D014376:Tuberculosis / Q000150:complications* / Q000188:drug therapy; D014397:Tuberculosis, Pulmonary / Q000150:complications / Q000188:drug therapy; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents; D000995:Antitubercular Agents