The real-world impact of new government guidelines

How new official guidelines for treating HIV are affecting patients in rural Malawi.

By Robbie Flick, Health Programs Coordinator, Malawi

In 2010, the World Health Organization issued bold new guidelines for the management of HIV in poor settings. Two were particularly groundbreaking: initiating anti-retroviral therapy (ART) to patients at earlier stages of the disease, and providing ART to all HIV-positive mothers who are breastfeeding their children.

The first specified starting ART when a patient’s CD4 count (a measure of immune system strength) drops to 350 of the previously recommended 200.  This means that patients begin life saving ART to fight HIV when their immune system is stronger which has been shown to greatly reduce disease burden and mortality. The second guideline virtually eliminates the chance of mother-to-child transmission of HIV. 

Five months ago here in Malawi, the Ministry of Health not only adopted this agenda, but went one step further by providing ART for HIV-positive pregnant mothers for life, helping to protect future children from HIV while providing a plethora of health benefits to the mother.

This agenda filled my thoughts as I traveled down the bumpy, intermittently passable road to Nsambe village. Nsambe is remote and beautiful, surrounded by domes of striated rock, with gently rolling hills punctuated by terraced plots of tilled land extending to the horizon’s blue fog. It is also viscerally poor. Tucked away in the southwest corner of Malawi against the Mozambique border, it feels forgotten by both countries.

I came to Nsambe to understand the real-world impact of ART and the new guidelines by attending an ART clinic conducted in partnership by PIH’s sister organization in Malawi, Abwenzi Pa Za Umoyo (APZU), and the Malawian Ministry of Health. We arrived at the health center and found the long, simple brick structure buzzing with activity.  ART clerks took height and weight measurements for each patients, while Ministry of Health officials organized treatment regimens of brightly colored pills into ziplock bags, with dosing and timing information clearly indicated in black permanent marker.  Staff dressed in sterile white uniform ferried boxes of drugs, food, and paperwork between departments. Exam room doors periodically squeak open and shut as clinicians examine their patients.  I was struck by the harmony of all the different parts working together to bring dignity and care to people living with HIV in this underserved area.

I spent my day with Maggie, an ART clinician with an intense gaze that conveys both her deep passion and compassion for this work and these patients. I noticed how her compassion influences her work—a gentle question, a comforting touch, and a look of concern that immediately put her patients at ease.

I quickly realized the profound impact of ART care directed by the new guidelines through the stories of Maggie’s patients. The first patient we saw tested positive for HIV earlier this year, but her CD4 count was too high to initiate ART. Now pregnant, the old guidelines would have put her on ART monotherapy in her third trimester, but only until the birth of her child. Under the new guidelines, Maggie was able to immediately start her on a robust triple therapy drug-regimen, allowing her to begin fighting the infection early in her pregnancy and dramatically reducing the chance of transmission to her child.  Further, she will continue ART for life, providing greater protection to her child while breastfeeding and even further reducing the chance of transmission for future children. Maggie also wasted no time in arranging for her to attend group therapy to help address the psychological burden of the disease.

Later we saw Janet, a community health worker for APZU. Several years ago, she was sick from a co-infection of both tuberculosis and HIV. APZU’s outreach ensured that she received the drugs she needed, and she has been on ART ever since. Today, she is fit, healthy, and capable of working the long days required of health workers. In fact, she had come to the clinic with another woman who was seven months pregnant. Maggie prescribed the life-saving drugs for her that day.

These patient stories were echoed in the stories of other patients I met throughout the day. The bold new guidelines and PIH’s partnership with the Ministry of Health to implement them in underserved areas are truly helping patients receive the life-saving treatment they need to remain healthy, and to dramatically reduce the chance of transmitting the virus to their children.

By necessity, guidelines like those impacting the patients I saw at Nsambe are formulated in hermetic conference rooms insulated from the gritty reality of the patients suffering from complex diseases. Yet, the human stories I’ve heard here in rural Malawi boldly underscore the value of ambitious government guidelines and PIH’s human rights-based approach in delivering services to the district’s most vulnerable individuals.  Without these two components, patients are needlessly denied access to the only intervention that will prolong life, reduce the burden of disease, and protect their children from transmission.