Malawi is facing an ugly AIDS treatment dilemma. They Ministry of Health has decided to change national treatment standards to meet WHO guidelines for optimal HIV care. That means adding new drugs to the treatment regimen and starting HIV treatment when a patient’s CD4 count, a measure of immune system strength, drops below 350 rather than waiting for it to sink to 200. It will also cost three times as much.

HIV advocates in Malawi are worried. Right now, the government provides HIV care free of charge to about 250,000 people identified as needy. If treatment becomes more expensive and health budgets remain the same, fewer people get AIDS care. The new regimen is in keeping with the WHO standard. It’s not some crazy expensive new method. It’s still behind AIDS care in the US, where they begin ART when the CD4 counts reach 500.

The old regimen was more equitable, in that it allowed more people to access HIV care. The new regimen will be more effective – people who get care will live longer. There is public health benefit either way. While the old way would help more people, the new way will reduce viral loads in people living with AIDS and theoretically reduce transmission.

I don’t really know how you make a decision like that. You can cede the decision to the WHO – trust their research and use their guidelines, like the government of Malawi has chosen to. You can chose equity above all other choices, as AIDS advocates in Malawi are calling for. Ideally, I guess, it’s not a zero-sum game, and you can dedicate more resources to HIV care. In a poor country, that’s not always an option. It’s an ugly choice.

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