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A Public Health Approach to Rapid Scale-Up of Antiretroviral Treatment in Malawi During 2004-2006

Lowrance, David W MD, MPH*; Makombe, Simon Dip Clin Med; Harries, Anthony D MD†‡§; Shiraishi, Ray W PhD; Hochgesang, Mindy MPH; Aberle-Grasse, John MPH; Libamba, Edwin MBBS; Schouten, Erik MD†#; Ellerbrock, Tedd MD*; Kamoto, Kelita MBBS

JAIDS Journal of Acquired Immune Deficiency Syndromes: November 2008 - Volume 49 - Issue 3 - p 287-293
doi: 10.1097/QAI.0b013e3181893ef0
Epidemiology and Social Science

Background: Approximately 1 million people are infected with HIV in Malawi, where AIDS is the leading cause of death in adults. By December 31, 2007, more than 141,000 patients were initiated on antiretroviral treatment (ART) by use of a public health approach to scale up HIV services.

Methods: We analyzed national quarterly and longitudinal cohort data from October 2004 to December 2006 to examine trends in characteristics of patients initiating ART, end-of-quarter clinical outcomes, and 6- and 12-month survival probability.

Findings: During a 27-month period, 72,666 patients were initiated on ART, of whom about two-thirds were women. The percentage of patients initiated on ART who were children and farmers increased from 5.5% to 9.0% and 23% to 32%, respectively (P < 0.001 for trends). Estimated survival probability ranged from 85% to 88% at 6 months and 81% to 84% at 12 months on ART.

Interpretation: In Malawi, a public health approach to ART increased treatment access and maintained high 6- and 12-month survival. Resource-limited countries scaling up ART programs may benefit from this approach of simplified clinical decision making, standardized ART regimens, nonphysician care, limited laboratory support, and centralized monitoring and evaluation.

From the *HIV/AIDS Care and Treatment Branch, Global AIDS Program, US Centers for Disease Control and Prevention, Atlanta, GA; †Clinical HIV Unit, Ministry of Health, Lilongwe, Malawi; ‡Family Health International, Arlington, VA; §London School of Hygiene and Tropical Medicine, London, United Kingdom; Epidemiology and Strategic Information Branch, Global AIDS Program, Centers for Disease Control and Prevention, Atlanta, GA; ¶Global AIDS Program, Centers for Disease Control and Prevention, Lilongwe, Malawi; and #Management Sciences for Health, Cambridge, MA.

Received for publication February 20, 2008; accepted August 5, 2008.

The findings and conclusions in this article are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

We declare that we have no conflicts of interest in regard to the findings contained in this article.

Correspondence to: David W. Lowrance, MD, MPH, Global AIDS Program, Centers for Disease Control and Prevention-Rwanda; 2657 Avenue Gendermarie, P.O. Box 28, Kigali, Rwanda (e-mail:

© 2008 Lippincott Williams & Wilkins, Inc.