Editor—The cover photograph of 30 March showing a patient's lunchtime drug treatment for HIV disease, held in his hand, speaks volumes over any written word. My colleagues and I, currently working at a rural mission hospital in Central Malawi, now all agree that antiretroviral drugs such as these are simply not a practical option for our patients with HIV/AIDS.
The hospital serves a population of 237 000, who are mainly subsistence farmers growing cassava and maize to make nsima, the staple carbohydrate food. The district covers some 3000 km2, and the capital, Lilongwe, is 210 km away. The prevalence of HIV here is conservatively estimated at one third of the population.
Yet it is not this large number of potential clients needing antiretroviral drugs that makes us pessimistic about their use. Neither is it the logistical challenge, with so few healthcare workers, of distribution and collection in this rural setting, especially in the rainy season when roads are impassable. The cost of the drugs is certainly an issue, although this has fallen significantly. The monthly income for farmers and their families is seasonal and highly variable, averaging just 1500 Malawi Kwacha a month—less than £14.
Simply finding a glass of clean drinking water to take the antiretroviral drugs is not guaranteed. Neither is compliance with the regimen of four times daily since most farmers do not have watches or clocks. The required monitoring of liver and marrow function while taking antiretroviral drugs could be done at the teaching hospital, were transport available. Drug interactions, especially with treatment of tuberculosis, would pose yet more problems since many people have both diseases. Simple side effects lessen compliance with and adherence to antiretroviral treatment. Completing just a five day course of antibiotics or antimalarial drugs is a rare achievement here. Drug resistance seems to be inevitable.
Thanks to your photograph, our conclusion on using antiretroviral drugs was drawn simply on the suggested triple therapy, multidosing regimen: “If I have to take all these just for lunch, where is the room for my nsima?” This is not just for some days or weeks, but for life. Education on preventing HIV has to be our main way forward, especially when all of our resources are so scarce.
Figure.
AMY SANCETTA/AP
How many antiretroviral drugs for HIV infection?