Malawi: Assessment of equity in the uptake of anti-retrovirals

http://www.equinetafrica.org/bibl/docs/DIS58FINmuula.pdf  

Table of contents

Executive summary  2
1. Introduction  4
2. Methodology and objectives of this study  5
3. Results of this study  6
    3.1 Estimated distribution of HIV-infected people in Malawi  6
    3.2 Numbers of patients on ART in Malawi  7
    3.3 Children and highly active retroviral therapy (HAART)  8
    3.4 Children and HAART: Some equity issues  8
    3.5 Distribution of patients on ART by gender  9
    3.6 Voluntary counselling and testing (VCT) and gender equity  11
    3.7 Impact of the free ART programme on patient numbers  11
    3.8 Occupational categories of patients  11
    3.9 Patient drug adherence in ART programmes  13
    3.10 Programme costs of Malawi's ART programme  14
    3.11 Equity analysis according to income of patients  14
    3.12 Qualitative research results  16
4. Conclusion and recommendations  17
References  19
Acronyms
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Cite as:
Muula AS and Kataika E (2008) ‘Assessment of equity in the uptake of anti-retrovirals in Malawi,’ EQUINET Discussion Paper Series 58. Regional network for Equity in Health in East and southern Africa (EQUINET)/ Health Economics Unit, University of Cape Town: Harare.

Executive summary

Malawi, like the rest of southern Africa, has a high adult HIV prevalence (estimated at about 12% in 2004) yet the country’s health sector is crumbling under severe pressure, largely due to limited investment. In 2004, the government of Malawi mobilised further local and international resources to commit itself to providing free antiretroviral therapy (ART) free to all patients, based on clinical need, in a large public sector-led programme.

This study was implemented under the fair financing theme in the Regional Network for Equity on Health in East and Southern Africa (EQUINET) and co-ordinated by the Health Economics Unit of the University of Cape Town. It aimed to assess equity in uptake of antiretroviral therapy in Malawi in 2005, especially according to age (children vs. adults), gender (men vs. women) and income. Particular reference is made to the scaling up of ART and the removal of fees for ART in 2004.

Informal interviews were conducted with health sector antiretroviral programme implementers and key policy makers in the Ministry of Health. The purpose of these interviews was to obtain their perceptions and experiences on a selected list of key issues affecting antiretroviral treatment rollout in the country. An interview guide was used. We also searched both published and grey literature to collect information on the history and operations of the Malawi public sector-led ART programme.

There were an estimated 11.9 million people in Malawi in 2004 – 5.5 million resident in the south, 5 million in the central region and 1 million in the north. The national adult (15- 49 years) HIV prevalence was 11.8%, with the highest prevalence in the south (17.6%), followed by the north (8.1%) and the central region (6.5%). From the data on the distribution of the population by age and HIV prevalence estimates among adults and children, there were an estimated 831,990 infected people, of whom 748,007 (89.9%) were adults and 10.1% were children.

Retention rates remain high in Malawi's ART programmes (84%), which compare favourably with those elsewhere on the continent. Retention rates ranging from 44% to 85% after 24 months of treatment have been reported in ART programmes throughout Africa (Rosen et al, 2007). While there were some reports from key informants that the change from fee-paying ART services to free systems may have improved patient adherence to treatment regimes, the research did not provide conclusive evidence of the impact of cost of patients' medications on their adherence to their treatment regimens.

Different adherence rates in different areas and programmes suggest that other determinants may be affecting affect this outcome. We suggest that there be further exploration of the barriers to treatment that men and children face in accessing care in Malawi, and further assessment of the factors affecting adherence. Although children make up about 10% of Malawi's HIV+ population, they only comprise 5% of the total number of people receiving HAART, which suggests that they are underrepresented by about 50%. In the Malawi District Health Survey (DHS), conducted in 2004, it was discovered that, among people aged 15 to 24 years, HIV prevalence was 3.9% in males versus 9.5% in females. However, for the age spectrum of 15-49 years, male prevalence was 11.2% compared to 11.8% in females.

This suggests that there was a significant disparity in terms of HIV prevalence between young male and female adults (15 to 24 years) but not between older male and female adults. While higher prevalence rates in young women may be a cause, the reasons need to be further explored. Social taboos against infidelity may also play a role in explaining why more women seek testing, with men reluctant to go for an HIV test because it's seen as an admission of infidelity. Another explanation that was offered was that prevention of mother-to-child-transmission programmes allow women to be diagnosed when they seek maternal car. There was, however, no clear evidence for this.

We uncovered some inequities that negatively affected the poorest quintile of the population (the poorest 20%). Based on reported illness and service uptake in the four weeks before the survey, we compared the poorest 20% of those people on ART with the richest 20%. We noted that the poorest 20% are more likely to be ill, less likely to access doctors and less likely to see a doctor when they fall ill than the richest 20% in both rural and urban areas. In the urban areas, the differences in levels of access and utilisation were not statistically significant (t-ratio = 1.36), but in rural areas, the differences were much higher and statistically significant (t-ratio = 2.73).

Our study was limited by a lack of relevant and reliable data; this points to an urgent need for further research into equity in ART programmes in Malawi. Hopefully, our equity analysis will be used by public health services planners and programme implementers in the future to identify and deal with inequitable gaps in ART coverage.

4. Conclusion and recommendations

Our analysis of the Malawi HIV treatment programme has found that men and children are under-represented in the programme. It would appear that, while there were almost equal proportions of women and men or only a slight under-representation of men when treatment was available at cost to patient, free treatment has been largely associated with a predominance of female patients. The situation among children continues to improve. According to key informant interviews, the increase in the proportion of children on treatment was possible as a result of the completion of the Paediatric Treatment Guidelines by the Ministry of Health.

While there were some reports from key informants that the change from fee-paying ART services to free systems may have improved patient adherence to treatment regimes, the research did not provide conclusive evidence of the impact of cost of patients' medications on their adherence to their treatment regimens. Different adherence rates in different areas and programmes suggest that other determinants may be affecting affect this outcome. We suggest that there be further exploration of the barriers to treatment that men and children face in accessing care in Malawi, and further assessment of the factors affecting adherence.

Key respondents also believed that gradually more men would be educated about ART through the women in their lives and it was only a matter of time before they would start realising the benefits of seeking ART, especially the fact that it could save their lives. As treatment programmes mature, the gender disparities in the proportion of patients accessing treatment are expected to diminish.

We uncovered some inequities that negatively affected the poorest quintile of the population (the poorest 20%). Based on reported illness and service uptake in the four weeks before the survey, we compared the poorest 20% of those people on ART with the richest 20%. We noted that the poorest 20% are more likely to be ill, less likely to access doctors and less likely to see a doctor when they fall ill than the richest 20% in both rural and urban areas. In the urban areas, the differences in levels of access and utilisation were not statistically significant (t-ratio = 1.36), but in rural areas, the differences were much higher and statistically significant (t-ratio = 2.73).

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Adamson S Muula and Edward Kataika
the University of Malawi,
Department of Community Health and
College of Medicine
Blantyre, Malawi
and
Regional Network for Equity in Health in east and southern Africa (EQUINET)
Health Economics Unit
University of Cape Town.  

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