Malawi's contribution to "3 by 5": achievements and challenges.
OBJECTIVE
Many resource-poor countries have started scaling up antiretroviral therapy (ART). While reports from individual clinics point to successful implementation, there is limited information about progress in government institutions at a national level.


METHODS
Malawi started national ART scale-up in 2004 using a structured approach. There is a focus on one generic, fixed-dose combination treatment with stavudine, lamivudine and nevirapine. Treatment is delivered free of charge to eligible patients with HIV and there is a standardized system for recruiting patients, monthly follow-up, registration, monitoring and reporting of cases and outcomes. All treatment sites receive quarterly supervision and evaluation.


METHODS
In January 2004, there were nine public sector facilities delivering ART to an estimated 4 000 patients. By December 2005, there were 60 public sector facilities providing free ART to 37,840 patients using national standardized systems. Analysis of quarterly cohort treatment outcomes at 12 months showed 80% of patients were alive, 10% dead, 9% lost to follow-up and 1% had stopped treatment.


CONCLUSIONS
Achievements were the result of clear national ART guidelines, implementing partners working together, an intensive training schedule focused on clinical officers and nurses, a structured system of accrediting facilities for ART delivery, quarterly supervision and monitoring, and no stock-outs of antiretroviral drugs. The main challenges are to increase the numbers of children, pregnant women and patients with tuberculosis being started on ART, and to avert high early mortality and losses to follow-up. The capacity of the health sector to cope with escalating case loads and to scale up prevention alongside treatment will determine the future success of ART delivery in Malawi.
Libamba
Edwin
E
Clinical HIV Unit, Ministry of Health, Lilongwe, Malawi.
Makombe
Simon D
SD
Harries
Anthony D
AD
Schouten
Erik J
EJ
Yu
Joseph Kwong-Leung
JK
Pasulani
Olesi
O
Mhango
Eustice
E
Aberle-Grasse
John
J
Hochgesang
Mindy
M
Limbambala
Eddie
E
Lungu
Douglas
D
D000293:Adolescent; D000328:Adult; D044966:Anti-Retroviral Agents / Q000191:economics / Q000600:supply & distribution* / Q000627:therapeutic use; D002648:Child; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000191:economics; D006297:Health Services Accessibility / Q000191:economics / Q000458:organization & administration*; D006301:Health Services Needs and Demand; D006801:Humans; D008295:Malawi; D008297:Male; D015397:Program Evaluation; D011635:Public Health Administration; D017150:Public Sector; D040841:Resource Allocation / Q000191:economics / Q000458:organization & administration*
D044966:Anti-Retroviral Agents