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

PLOS ONE, Dec 2006

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 (X2 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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Acceptance of Anti-Retroviral Therapy among Patients Infected with HIV and Tuberculosis in Rural Malawi Is Low and Associated with Cost of Transport

et al (2006) Acceptance of Anti-Retroviral Therapy among Patients Infected with HIV and Tuberculosis in Rural Malawi Is Low and Associated with Cost of Transport. PLoS ONE 1(1): e121. doi:10.1371/journal.pone.0000121 Acceptance of Anti-Retroviral Therapy among Patients Infected with HIV and Tuberculosis in Rural Malawi Is Low and Associated with Cost of Transport Rony Zachariah 0 1 2 Anthony David Harries 0 1 2 Marcel Manzi 0 1 2 Patrick Gomani 0 1 2 Roger Teck 0 1 2 Mit Phillips 0 1 2 Peter Firmenich 0 1 2 0 Funding: The joint TB-HIV support program, including ART in Thyolo, is supported by Medecins sans Frontieres-Brussels. We are grateful to Family Health International, USA, the Department for International Development (DFID), the Norwegian Agency for Technical Cooperation (NORAD), the Royal Dutch TB Association (KNCV) , USAID, STOP-TB, WHO, and CIFF for supporting TB and TB-HIV control country-wide in Malawi 1 Academic Editor: Dee Carter, University of Sydney , Australia 2 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 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 (X2 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. - INTRODUCTION Tuberculosis (TB) is one of the most common causes of morbidity and mortality in HIV positive populations [1,2] and TB often brings the HIV-positive individual to medical attention. Since TB patients constitute a readily identifiable group in the health system for HIVtesting, they thus offer an opportunity for introducing HIV-related interventions including antiretroviral treatment (ART) [3]. Malawi, a small resource-poor country in southern Africa, has an estimated national HIV prevalence rate of 9%,[4] and 77% of new patients registered with TB are co-infected with HIV [5]. The Malawi ART guidelines [6] recommend that HIV-positive individuals assessed to be in World Health Organization (WHO) clinical stages III and IV are eligible for ART. As HIV-positive individuals with pulmonary TB (PTB) are classified as WHO stage III and those with extrapulmonary TB (EPTB) as WHO stage IV, all such TB patients are considered eligible for ART in Malawi. In Thyolo district, rural southern Malawi, ART was initiated in the main public hospital of the district in early 2003. However, despite a systematic offer of ART to all HIV-positive TB patients, acceptance of ART in this group was found to be at a low 13% [7]. It is likely that multiple factors might be influencing ART acceptance in HIV-positive TB patients in this setting, but these are at present not well characterized. We hypothesized that the cost of transport to a single, centralized ART delivery site in a poor rural setting where public transport networks are poorly developed is likely (...truncated)


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Rony Zachariah, Anthony David Harries, Marcel Manzi, Patrick Gomani, Roger Teck, Mit Phillips, Peter Firmenich. Acceptance of Anti-Retroviral Therapy among Patients Infected with HIV and Tuberculosis in Rural Malawi Is Low and Associated with Cost of Transport, PLOS ONE, 2006, Volume 1, Issue 1, DOI: 10.1371/journal.pone.0000121