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Acceptance of Anti-Retroviral Therapy among Patients Infected with HIV and Tuberculosis in Rural Malawi Is Low and Associated with Cost of Transport
Global Health Sciences Literature Digest
Published April 26, 2007
Journal Article

Zachariah R, Harries AD, Manzi M, Gomani P, Teck R, Phillips M, Firmenich P. Acceptance of Anti-Retroviral Therapy among Patients Infected with HIV and Tuberculosis in Rural Malawi Is Low and Associated with Cost of Transport. PLoS ONE. 2006 Dec 27;1:e121.


(a) To determine the acceptance of antiretroviral treatment (ART) among newly registered HIV-positive tuberculosis (TB) patients; (b) to conduct a geographic mapping of those placed on ART; and (c) to examine the association between "cost of transport" and ART acceptance.

Study Design

Retrospective cross-sectional analysis on routine program data.


The main public hospital in Thyolo district, rural Southern Malawi, during the period of February 2003 to July 2004. Thyolo district has approximately 500,000 inhabitants. ART was initiated in the main hospital in early 2003.


All newly registered HIV-positive TB patients presenting to Thyolo Hospital were included in the study. Of 1290 newly registered TB patients, 1003 (78%) underwent HIV testing, of whom 770 (77%) were HIV-positive. Seven hundred forty-two were considered eligible for ART, and 716 were placed on cotrimoxazole prophylaxis. Of the 742 ART-eligible patients, 420 were women and 322 were men; the median age was 32 years (range 2-70); 376 were married (51%), while 366 were single (unmarried, divorced or widowed); 607 (82%) individuals had pulmonary TB (smear-positive or negative) and 135 had extrapulmonary TB. ART was systematically offered to all HIV-positive TB patients.


The first-line ART regimen in Malawi is a fixed-dose combination of stavudine (d4T), lamivudine (3TC) and nevirapine (NVP). Because of concern about drug interactions between rifampicin and nevirapine, ART is offered to all HIV-positive TB patients only after they complete the initial two months of anti-TB treatment. In contrast to the current centralized offer of ART, cotrimoxazole prophylaxis has been decentralized, along with anti-TB treatment, and the drug is made available in all health centers. HIV-positive TB patients are systematically informed of the offer of ART and requested to return to the hospital HIV-ART clinic eight weeks after starting anti-TB treatment in conjunction with a patient guardian to prepare for ART initiation. Once started on ART, patients are reviewed back at the HIV-ART clinic after two weeks. Provided there are no side effects, patients are then seen monthly at the ART clinic and given drugs every 28 days indefinitely. ART and anti-TB treatment are offered free of charge in Thyolo, and at the time of the study, the Thyolo hospital was the only ART delivery site in the district.

Primary Outcomes

Newly registered HIV-positive TB patients placed on ART were designated as the dependent variable for identifying potential associations. The predictor variables were as follows: distance of residence from the hospital and cost to get to the hospital from the residence, as well as gender, age, marital status, type of TB, and occupation. The place of residence, as indicated on the TB patient card and register, was used to determine road distances to the Thyolo district hospital. Cost of transport from different parts of the district was based on the known cost for public transport to the road-stop closest to the patient’s residence.


Of 742 HIV-positive TB patients who completed the intensive phase of anti-TB treatment and were offered ART, only 101 (13.6%) were started on ART. The median distance that HIV-positive TB patients had to travel to get to the Thyolo hospital for ART was 22 km (range 5 to 65 km) and the median cost for transport was 70 Malawi Kwacha (range 30 to 270 Kwacha, $1 USD=100 Malawi Kwacha). The association of distance from the ART site with uptake of ART was not statistically significant (those ≤ 20 km from the hospital had AOR=1.1 [95% CI 0.6-1.8] compared to those >20 km). The cost of transport to the hospital ART site, however, was significantly associated with ART acceptance. Individuals paying 50 Malawi Kwacha or less for a one-way trip to the Thyolo hospital were four times more likely (95% CI 2.0-8.1; p<0.001) and individuals paying between 50 and 100 Malawi Kwacha were 2.6 times more likely (95% CI 1.2-5.9; p=0.02) to take up the offer of ART than those paying 100 or more Malawi Kwacha. There was a linear trend in association between cost and ART acceptance (X2 test for trend=25.4, p<0.001). Notably, the payment of one USD for a return trip to an ART site accounted for at least 25% of weekly net revenue for most participants in the study.


The authors concluded that ART acceptance among TB patients in a rural district in Malawi is low and associated with cost of transport to the centralized hospital-based ART site. The higher the cost of transport to the hospital-based ART delivery site, the less probable it is that a TB patient accepts ART. The financial predicament of TB patients at the time of starting ART might mean that they are too impoverished to afford the cost of accessing ART.

Quality Rating

There is no quality rating system for cross-sectional studies. The strengths of the study were a large sample size and the fact that data came from a routine TB program setting, reflecting the reality on the ground. However, cross-sectional studies have little power to deal with possible confounders, such as education level, knowledge of HIV, or belief in ART efficacy. Furthermore, researchers did not interview study subjects and could not ask about barriers to care or other factors not measured. This study may not be generalizable to other settings where delivery method, distance, cost, and transport could be different.

In Context

The results of this study are supported by another recent study in Botswana showing a correlation between cost and uptake of ART.(3) Additionally, the patients in this study receive their monthly supply of cotrimoxazole along with anti-TB drugs at sites close to their home communities. The overall burden and particularly cost of transport is thus minimized. In contrast to ART, the uptake of cotrimoxazole in this cohort of patients is 93%, and other studies in the same setting have demonstrated that adherence to cotrimoxazole both during and after anti-TB treatment is close to 94%.(1-2) The lack of an association between distance to the hospital facility and ART uptake likely reflects the fact that cost of transport is much more related to the presence (or lack thereof) of public transport networks. Where public transport is well-developed, the cost for a given distance would be relatively less and vice versa.

Programmatic Implications

Given the relative ease of identifying TB patients and the high prevalence of TB/HIV co-infection, a great opportunity exists for introducing HIV-related interventions, including ART.(4) This study suggests that decentralizing ART to local health centers, as has been done for anti-TB treatment and cotrimoxazole, may improve uptake rates. Provision of ART, however, is resource-intensive, requiring qualified medical personnel and laboratory testing that may not be available in local areas. A balance of convenience and quality of care must be established in each area prior to implementing ART.


  1. Zachariah R, Harries AD, Arendt V, Wennig R, Schneider S, Spielmann M, et al. Compliance with cotrimoxazole prophylaxis for the prevention of opportunistic infections in HIV-positive tuberculosis patients in Thyolo district, Malawi. Int J Tuberc Lung Dis 2001 Sep;5(9):843-6.
  2. Zachariah R, Spielmann MP, Harries AD, Gomani P, Bakali E. Cotrimoxazole prophylaxis in HIV-infected individuals after completing anti-tuberculosis treatment in Thyolo, Malawi. Int J Tuberc Lung Dis 2002 Dec;6(12):1046-50.
  3. Bisson GP, Frank I, Gross R, Lo Re V 3rd, Strom JB, Wang X, et al. Out-of-pocket costs of HAART limit HIV treatment responses in Botswana's private sector. AIDS 2006 Jun 12;20(9):1333-6.
  4. Reid A, Scano F, Getahun H, Williams B, Dye C, Nunn P, et al. Towards universal access to HIV prevention, treatment, care, and support: the role of tuberculosis/HIV collaboration. Lancet Infect Dis 2006 Aug;6(8):483-95. Review.