Thyolo is a rural district in Malawi, a country in southern Africa which is among the ten most affected by HIV/AIDS worldwide. Among the district's 600,000 inhabitants, one out of five adults is living with HIV. Many are impoverished and authorities face a dire shortage of health workers. And yet, despite this very bleak outlook, the Ministry of Health, together with Médecins Sans Frontières (MSF), not only offer access to antiretroviral treatment to almost everyone who needs it, they do so at reasonable and affordable costs.

Marielle Bemelmans, MSF head of mission in Malawi, explains how this works and why the high prices of newer AIDS drugs put this great achievement in peril.

In Thyolo district, universal access to antiretroviral (ARV) treatment has become a reality. It means that at least eight out of ten people who need antiretroviral treatment are actually getting it – currently over 14 000 in total. How was it achieved?

“HIV care has been integrated into the public health system and standardised as far as possible. It includes only one standard first-line regimen of drugs and simplified laboratory monitoring. Also, services have been decentralised to smaller health centres. This also meant that medical responsibilities needed to be shifted to nurses and health workers. In a country with such an acute shortage of doctors, this task shifting strategy was crucial and allowed us to increase the number of people who start antiretroviral treatment four-fold.”

What are the benefits of this approach?

“A decentralised approach to public health means that people access treatment closer to their homes and consequently spend less money and time on transportation. More people in the district now know about the services and people have seen how family members, friends, and colleagues get better. This motivates them to come to the clinics, get tested and start treatment.

“Also, we have been able to start people on treatment much earlier before they get ill – their CD4 cell count at treatment initiation is now at an average of 250 which indicates that the immune system still works relatively well. The waiting period between the first test and the moment when patients take their first pill has been reduced from more than three months to three weeks on average.”

This all sounds fine, but is this approach affordable for a developing country like Malawi?

“At the moment, it costs 233 Euro to treat one patient for one year. This includes the antiretroviral drugs – which take up more than half of the budget – the cost of other drugs, laboratory tests, staff, support services and supervision. From the district’s perspective, the per capita financial burden for the AIDS treatment programme is 2.60 Euro per inhabitant per year. In developing countries, which often spend only between 10 and 20 Euro per capita on health services, it is still a significant cost – but it is doable.”

What would undermine sustaining the hard-won universal access to treatment in Thyolo?

“The main threat is the high prices of newer AIDS drugs. Let me explain: Today, more than 95 percent of patients in Thyolo take relatively cheap generic first-line antiretroviral drugs. First of all, there is a need to introduce a more robust first-line regimen with fewer side-effects. But even if patients take their first-line drugs regularly, they will inevitably need to change to newer second-line, or even third-line drugs after a couple of years.

“But most of these newer drugs are patented and are not yet available as cheaper generics. As more people will need to switch to newer drugs over the coming years, the costs of this programme will increase astronomically because of spiraling drug costs. The point is that we need to take all the necessary measures right now, to ensure competition between different companies producing generic drugs. This is the best way to get the newer drugs much, much cheaper.”