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Is Malawi ready for early HIV treatment?

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After her husband died of HIV and Aids, Esnart was heavily traumatised fearing that she was the next on the line knowing that the disease has created trauma to thousands of lives worldwide.

Esnart’s husband delayed in taking ARTs and the doctors found that his body immune system was low. Immediately he was put on life-prolonging drugs, ARVs.

“The doctor said his immunity (CD4 count) was very low and he was put on ARVs immediately. But it was too late, he didn’t respond to the treatment,” Esnart recalls.

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True to her fears, Esnart was also diagnosed HIV positive but was told to wait until her CD4 count reached 350 cells/mm3 for her to start taking Antiretroviral (ARV) drugs.

She explains that even though she was counselled before and after HIV testing, she could not appreciate why she needed to wait before starting to take ARVs.

“I witnessed my husband’s health deteriorating before he died. I was afraid that if I delay I could have my late husband’s experience. It was a death sentence to me,” Esnart recalls.

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Such fears have arisen because of the guidelines that Malawi and many other developing countries are following that one cannot begin taking ARVs until their CD4 count is 350 cells/mm3 or less.

Esnart might not be the only one but such distress would eventually go because of a recent Strategic Timing of Antiretroviral Treatment- START trial done by Aids Vaccine Advocacy Coalition (Avac) which has revealed that there are individual health benefits of beginning Antiretroviral Treatment (ART) immediately after being diagnosed with HIV regardless of the CD4 count status.

Earlier data from HPTN 052 provide strong evidence about the benefits of starting ART earlier.

START randomised trial was an investigation to find out whether immediate initiation of ART can improve individual health for people living with HIV and Aids.

The findings, which were released on May 27, 2015, enrolled 4,685 people at 215 sites in 35 countries (27 percent of the participants are women and approximately half are gay men).

It looked at rates of Aids and serious Aids-defining illness or death in people with CD4 cell counts above 500 cells/mm3 who started ART on enrolment in START, versus those participants who also had CD4 cell counts above 500 cells/ mm3 and delayed treatment until the initiation criteria dictated by the clinical guidelines in their countries.

The findings show that at a scheduled interim review of data, the trial’s Data and Safety Monitoring Board (DSMB) found compelling evidence that the benefits of starting ART immediately at CD4 cell counts above 500 cells/ mm3 outweigh the risks.

“This conclusion was based on the fact that over an average follow-up period of three years, the risk of Aids and other serious illnesses or death was reduced by 53 percent among those in the early treatment group versus those who started treatment according to national guidelines,” reads part of the report.

The report, however, stresses that START effectively validates the direction that World Health Organisation’s consolidated guidelines on the use of ARV drugs for treating and preventing HIV infection had begun to take initiation regardless of their CD4 cell count in many populations, including pregnant women, children under the age of five and people in sero-discordant couples (where one is HIV positive and the other negative).

The findings also cautions that it is critical to recognise that figuring out when to start is only part of the puzzle since the question of how to start is equally critical and is not going to be settled by any randomised trial.

“The how concerns the environments in which individuals are offered treatment, the services that are part of that offer-peer support, community-based refills, non-biased provider care, among others- and the ways the decision to start is framed. Even with clinical and public health benefits, ART may not be for everyone as soon as they are diagnosed,” says the report.

Perhaps one wonders if this is practical for a developing country like Malawi (whose HIV treatment entirely depends on donor funding) and has many people confused like Esnart.

Director of HIV and Aids in the Ministry of Health, Dr Frank Chimbwandira, says even though studies like START are done in a controlled environment, he agrees that ART administration immediately after diagnosis has more health benefits.

“Early initiation of ART’s implementation would be difficult in Malawi. There are several things that need to be considered including resource availability. This would mean ordering more drugs,” he said.

Chimbwandira points out the need for intensive civic education for some people to understand why they should be taking medication when they are not sick.

“This could be done concurrently with proper planning for more resources,” he says.

Executive Director for Health and Rights Education Programme, Maziko Matemba, says early ART could help the country achieve zero new HIV infections and zero Aids deaths.

“This is a good way of preventing HIV and Aids since one’s viral load is reduced when they are on ART. This calls for an increase in HIV and Aids financing because it means more people would be required to be on treatment,” he says.

Executive Director for Malawi Network of People Living with HIV and Aids (Manet+), Safari Mbewe, says his organisation totally supports START trial findings saying this is practical for Malawi.

“I’m very sure that government is thinking of introducing this since it has proven to have several advantages. The individual on treatment lives a healthy life [and] the society benefits since there are less chances of transmission and health service providers will no longer be bothered to test CD4 count,” he observes.

Mbewe adds: “HIV issues are about science so things have improved after research findings like these. Initially there were no studies done hence we had to stick to the initial guidelines. Now that we have evidence, let’s go for it.”

Executive Director for Malawi Healthy Equity Network (Mhen), Martha Kwataine, says even though early ART initiation suppresses viral load there is need to sensitise people that prevention is better than cure.

“Having the experience in community work, what I have noticed is that there is no behaviour change. It’s like people are saying ‘after all when I’m diagnosed with it, I will top up the ‘units’ as they call it (ART Drugs),” she says.

Kwataine adds: “Every medication has side effects and sometimes the body develops resistance after a long time on treatment. There are also issues of toxicity in the body which need to be considered.”

She further elaborates that although this is a good idea there are cost implications considering that Malawi currently relies on Global Fund for ART.

Kwataine wonders where the country would get the money to put all eligible on treatment

“We need to reshape our messages on behaviour change which is equally key in the fight against HIV and Aids.”

Above all, it is up to government to decide and determine fears that people like Esnart have since policy making lies within its mandate.

Malawi initiated ART in June 2003 courtesy of Global Fund. According to Ministry of Health there are one million people living with HIV in the country and 500,000 of them are on ART.

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