Act local, think global: how the Malawi experience of scaling up antiretroviral treatment has informed global policy.
The scale-up of antiretroviral therapy (ART) in Malawi was based on a public health approach adapted to its resource-poor setting, with principles and practices borrowed from the successful tuberculosis control framework. From 2004 to 2015, the number of new patients started on ART increased from about 3000 to over 820,000. Despite being a small country, Malawi has made a significant contribution to the 15 million people globally on ART and has also contributed policy and service delivery innovations that have supported international guidelines and scale up in other countries. The first set of global guidelines for scaling up ART released by the World Health Organization (WHO) in 2002 focused on providing clinical guidance. In Malawi, the ART guidelines adopted from the outset a more operational and programmatic approach with recommendations on health systems and services that were needed to deliver HIV treatment to affected populations. Seven years after the start of national scale-up, Malawi launched a new strategy offering all HIV-infected pregnant women lifelong ART regardless of the CD4-cell count, named Option B+. This strategy was subsequently incorporated into a WHO programmatic guide in 2012 and WHO ART guidelines in 2013, and has since then been adopted by the majority of countries worldwide. In conclusion, the Malawi experience of ART scale-up has become a blueprint for a public health response to HIV and has informed international efforts to end the AIDS epidemic by 2030.
International Union against Tuberculosis and Lung Disease, Paris, France. adharries@theunion.org.|London School of Hygiene and Tropical Medicine, London, UK. adharries@theunion.org.|Old Inn Cottage, Vears Lane, Colden Common, Winchester, SO21 1TQ, UK. adharries@theunion.org.
Anthony D
AD
Harries
Department of HIV and Hepatitis, World Health Organization, Geneva, Switzerland.
Nathan
N
Ford
HIV and AIDS Department, Ministry of Health, Lilongwe, Malawi.|ITECH, Malawi and University of Washington, Seattle, USA.
Andreas
A
Jahn
Management Sciences for Health, Lilongwe, Malawi.
Erik J
EJ
Schouten
HIV and AIDS Department, Ministry of Health, Lilongwe, Malawi.
Edwin
E
Libamba
HIV and AIDS Department, Ministry of Health, Lilongwe, Malawi.
Frank
F
Chimbwandira
Special Programme for Research and Training in Tropical Diseases, World Health Organization, Geneva, Switzerland.
Dermot
D
Maher
D000293:Adolescent; D000328:Adult; D023241:Antiretroviral Therapy, Highly Active / Q000706:statistics & numerical data*; D018791:CD4 Lymphocyte Count; D002648:Child; D002675:Child, Preschool; D005260:Female; D014943:Global Health; D015658:HIV Infections / Q000188:drug therapy / Q000453:epidemiology* / Q000517:prevention & control; D006295:Health Resources; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control; D008295:Malawi / Q000453:epidemiology; D008297:Male; D057766:Policy; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000188:drug therapy / Q000453:epidemiology* / Q000517:prevention & control; D011634:Public Health; D014944:World Health Organization; D055815:Young Adult
Antiretroviral therapy; HIV/AIDS; Malawi; Policy; World Health Organization