Cost of ART delivery in Malawi affordable within WHO-recommended health budget

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Total additional costs for sustaining universal access in a high prevalence, extremely poor rural area of Malawi are well within budget guidelines set by the World Health Organization for a minimal basic health package, reported Mary Bemelmans in a study presented at the Fifth IAS Conference on Pathogenesis, Treatment and Prevention in Cape Town, South Africa this week.

A Ministry of Health and Médècins sans Frontières (MoH-MSF) supported HIV programme achieved universal access in Thyolo, a rural area of Malawi where poverty rates are ten times higher than the national average with an HIV prevalence rate of 21%.

Of the 14,101 people who started treatment in the programme close to 80% were alive and in care at the end of 2007 and currently 80% remain in care.


first-line therapy

The regimen used when starting treatment for the first time.

retrospective study

A type of longitudinal study in which information is collected on what has previously happened to people - for example, by reviewing their medical notes or by interviewing them about past events. 


The origin and step-by-step development of disease.

second-line treatment

The second preferred therapy for a particular condition, used after first-line treatment fails or if a person cannot tolerate first-line drugs.

A “public health” approach has been integral to successful scale-up. Decentralisation of care along with the extensive use of task-shifting and the streamlining of patient flow together with high level community involvement were key to achieving rapid scale-up.

Between 2005 and the end of 2007 the mean CD4 count at treatment initiation rose from around 150 cells/mm3 to 250 cells/mm3, while the mean delay between diagnosis and treatment initiation fell from around 90 days to 40 days in the same period, due to the decentralisation of antiretroviral (ART) prescribing to primary health clinics and task-shifting of ART management to medical officers.

A retrospective cost-analysis of additional costs for HIV care and treatment for the period from 2005-2007 was undertaken.

Annual recurring costs amounted to €237, 67% (€158) of which was spent on antiretrovirals and a further 14% on other essential drugs. Human resources and general running costs accounted for 13%, with an additional 6% for laboratory expenses.

Drugs constitute the most significant cost. Human resource costs per patient declined over time due to task-shifting, from around €45 per patient per year in 2005 to €25 per person per year in 2007.

Universal access has been achieved in a high prevalence rural area of Malawi with a total population of 600,000 at an estimated annual cost per inhabitant of €3.20, said Matu Bemelmans.

Current national health expenditure per person is €13.20 per year. Achieving universal access to antiretroviral treatment cost “an additional €2.60 per person, well within the estimated minimal basic health package costs” [as determined by the World Health Organization], she concluded, but warned of potential for considerable cost increases over time due to the anticipated demand for alternatives to the current first-line treatment regimen, and for second-line antiretroviral treatment, which is currently twelve times more expensive than first-line treatment in Malawi.

Further information

A powerpoint presentation by Marielle Bemelmans and a webcast of the conference session in which it was presented are available on the IAS 2009 website.