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      Acceptance of Anti-Retroviral Therapy among Patients Infected with HIV and Tuberculosis in Rural Malawi Is Low and Associated with Cost of Transport

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          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.

          Methodology/Principal Findings

          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 (X 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/Significance

          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.

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          Most cited references23

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          Towards universal access to HIV prevention, treatment, care, and support: the role of tuberculosis/HIV collaboration.

          Christopher Dye, Catherine Hankins, Newton G. Castro … (2006)
          Tuberculosis is the oldest of the world's current pandemics and causes 8.9 million new cases and 1.7 million deaths annually. The disease is among the most common causes of morbidity and mortality in people living with HIV. However, tuberculosis is more than just part of the global HIV problem; well-resourced tuberculosis programmes are an important part of the solution to scaling-up towards universal access to comprehensive HIV prevention, diagnosis, care, and support. This article reviews the impact of the interactions between tuberculosis and HIV in resource-limited settings; outlines the recommended programmatic and clinical responses to the dual epidemics, highlighting the role of tuberculosis/HIV collaboration in increasing access to prevention, diagnostic, and treatment services; and reviews progress in the global response to the epidemic of HIV-related tuberculosis.
          Article 0 comments Cited 32 times – based on 0 reviews     Review now
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            Joint United Nations Programme on HIV/AIDS (UNAIDS)-WHO. Revised recommendations for the selection and use of HIV antibody tests.

            (1997)
            Article 0 comments Cited 26 times – based on 0 reviews     Review now
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              Cost and cost-effectiveness of increased community and primary care facility involvement in tuberculosis care in Lilongwe District, Malawi.

              K. Floyd, J Skeva, T. Nyirenda … (2003)
              Lilongwe District, Malawi. To assess the cost and cost-effectiveness of new treatment strategies for new pulmonary tuberculosis patients, introduced in 1997. For new smear-positive pulmonary patients, two strategies were compared: 1) the strategy used until the end of October 1997, involving 2 months of hospitalisation at the beginning of treatment, and 2) a new decentralised strategy introduced in November 1997, in which patients were given the choice of in- or outpatient care during the first 2 months of treatment. For new smear-negative pulmonary patients, the two strategies compared were 1) the strategy used until the end of October 1997, which did not require any direct observation of treatment (DOT) and 2) a new community-based strategy introduced in November 1997, which required DOT by a community member 'guardian' or a health worker for the first 2 months of treatment. Costs were analysed from the perspective of health services, patients, and the community in 1998 US dollars, using standard methods. Cost-effectiveness was calculated as the cost per patient cured (smear-positive cases) and as the cost per patient completing treatment (new smear-negative cases). For new smear-positive patients, the cost per patient treated was dollars 456 with the conventional hospital-based strategy, and dollars 106 with the new decentralised strategy. Costs fell by 54% for health services and 58% for patients. The cost per patient cured was dollars 787 for the conventional hospital-based strategy, and dollars 296 for decentralised treatment. For smear-negative patients, the cost per patient treated was dollars 67 with the conventional unsupervised strategy, and dollars 101 with the community-based DOT strategy. Costs increased for health services, patients and guardians. Cost-effectiveness was similar with both strategies, at around dollars 200 per patient completing treatment. When new smear-positive and new smear-negative patients were considered together, the new strategies were associated with a 50% reduction in total annual costs. There is a strong economic case for expansion of decentralisation and community-based DOT in Malawi. Further investment in training and programme supervision may help to increase effectiveness.
              Article 0 comments Cited 25 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                : Role: Academic Editor
                Journal
                Journal ID (nlm-ta): PLoS ONE
                Journal ID (publisher-id): plos
                Title: PLoS ONE
                Publisher: Public Library of Science (San Francisco, USA )
                ISSN (Electronic): 1932-6203
                Publication date Collection: 2006
                Publication date (Electronic): 27 December 2006
                Volume: 1
                Issue: 1
                Electronic Location Identifier: e121
                Affiliations
                [1 ]Medecins sans Frontieres, Medical Department (Operational Research), Brussels Operational Center, Brussels, Belgium
                [2 ]Ministry of Health, HIV Care and Support, Lilongwe, Malawi
                [3 ]Ministry of Health and Population, Thyolo District Health Services, Thyolo, Malawi
                [4 ]Medecins sans Frontieres, Thyolo, Malawi
                [5 ]Medecins sans Frontieres, Access to Health, Brussels, Belgium
                [6 ]Medecins sans Frontieres, Operations Department, Brussels Operational Center, Luxembourg
                University of Sydney, Australia
                Author notes
                * To whom correspondence should be addressed. E-mail: zachariah@ 123456internet.lu

                Conceived and designed the experiments: AH RZ MM PG RT. Performed the experiments: PG RT. Analyzed the data: RZ MM PG MP PF. Contributed reagents/materials/analysis tools: AH RZ MM MP PF. Wrote the paper: AH RZ MM PG RT MP PF.

                Article
                Publisher ID: 06-PONE-RA-00074R3
                DOI: 10.1371/journal.pone.0000121
                PMC ID: 1762339
                PubMed ID: 17205125
                SO-VID: e9bce89f-735d-46f1-b7f3-2d993e9fc406
                Copyright © Zachariah et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
                History
                Date received : 25 August 2006
                Date accepted : 23 November 2006
                Page count
                Pages: 6
                Categories
                Subject: Research Article
                Subject: Infectious Diseases/HIV Infection and AIDS
                Subject: Public Health and Epidemiology/Health Policy

                ScienceOpen disciplines: Uncategorized
                Data availability:
                ScienceOpen disciplines: Uncategorized

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