Towards an HIV-free generation in Malawi township
30 September 2016 - It’s a sunny July Wednesday, and the Ndirande Health Centre in the outskirts of Blantyre, Malawi is buzzing. At the health centre, which serves the largest township of 300 000 people in Malawi's financial capital, some 10 500 patients with HIV routinely receive antiretroviral therapy (ART). Among them are 6 000 mothers and their children. The clinic is particularly full today, as Wednesday is "mother and baby" day.
The clinic provides universal treatment to all mothers, most of whom are tested for HIV the first time they are pregnant. Dr Martha Makwero, an obstetrician and gynaecologist educated in South Africa, is the only doctor overseeing the health centre today. The clinic effectively operates as a "task shifting” based site, with many services provided by clinical officers, nurses and community health workers, but not full-time doctors. Most patients visit routinely to refill prescriptions for HIV medicines, so visiting doctors such as Dr Makwero can focus on patients who have complicated issues or worries.
Martha Namanya is an ART clerk who has been trained to take patient records. She ensures all patient information is fully recorded in both hard copy and electronic systems, so patients can have their prescriptions filled without delay. Patients have health passports with barcodes, so once their records have been completed in the system, a single scan is all it takes to get their medications.
On this particular day, a young mother named Love Saidi is collecting antiretrovirals for her husband who is at work. Love came to the clinic with her husband in January 2015, when she was 3 months pregnant, to start her antenatal care. She immediately learnt that she was HIV positive and so was her husband. She was offered free HIV medicines under the WHO-recommended “Option B” scheme, which aims to ensure all HIV-positive mothers start early and lifelong HIV treatment.
By starting HIV treatment early, Love was able to ensure her baby, Patience, was born HIV-free. Her husband was also put on treatment. "It would have been a double blow if my baby was born with HIV," said Love. "Although I was pained to discover it at first, I feel fine now I’m on treatment. It is better to know and start treatment early, before getting sick."
With high unemployment rates and seemingly endless social issues, the risk of HIV feels ever-present in this impoverished neighbourhood. Many women only discover their HIV infection after they become pregnant. Community health workers like Chifundo Mahamba play a crucial role in helping these pregnant women and mothers get started and remain in HIV care.
Chifundo has been working at the health centre for 7 years as a “mothers2mothers” patient expert. She helps women on antenatal visits take HIV tests. Those who are negative still receive visits from a mothers2mothers patient expert for repeat HIV tests, and come again with their partners for HIV testing. Pregnant women who are HIV positive are offered ART, and receive home visits over the following weeks and months to ensure they are following the treatment correctly. Chifundo receives a modest wage of 46 000 kwachas (approximately US$ 64) and has to visit families living as far as 10 km away.
Dr Makwero says the health centre manages to catch most HIV-positive mothers when pregnant and get them started on treatment. In fact, most of their babies are born without HIV, thanks to the universal treatment programme for all pregnant women with HIV. Life in the community can be difficult, given high unemployment rates and low levels of social care. Yet, the Ndirande Health Centre is making it possible to break the cycle of HIV infections, and with it the accompanying disease and despair. "Low-cost innovations are what it takes," says Dr Makwero. "Task shifting, better records and good engagement by community health workers are doable. When we had [to use] the lower threshold CD4 count of 200, so many people were sick and bedridden. Now that we start patients earlier on treatment, people are healthier and services can be run at a lower cost."
We asked Dr Makwero her opinion on the impending "treat-all" policy, which means starting every HIV-positive person on treatment as soon as they are diagnosed. "I'm very excited about ‘treat-all’,” she said. “Treating early is cost-effective for the community, and of course much better for the family." Just 3 weeks after our conversation, Malawi’s Ministry of Health announced an official policy to offer "treat-all" for all people living with HIV.