One step forward, two steps back

One of Malawi’s (and the world’s) toughest obstacles in the fight against AIDS is that some HIV-infected individuals do not want treatment or seek treatment too late. The reasons for not wanting, or delaying, treatment are of course complex and multifaceted. I do not pretend to understand them all. But, some of the most common reasons are: 1) denial about being infected even after a positive test; 2) fear of disclosing HIV status to someone (you MUST bring a guardian to get HIV treatment in Malawi - more on this later); 3) lack of desire to take life-long meds; 4) believing that you only have to start meds when you are really sick – a time for some that is always in the future. There are hundreds of other reasons why people do not start, or remain, on treatment.

Still, a man died from TB today in the hospital –his lungs were so bad that people described the Xray as “looking like corn in the lungs.” He had started TB treatment 3 days previous. He also had AIDS but was not yet on treatment. He had tested HIV positive months, if not years, ago. Clearly, it was too late by the time he got treatment.

This situation is not unusual -- it happens dozens of times every day -- and almost 70% of people in Malawi with TB are also HIV infected. However, this case was different: the deceased man’s brother runs an HIV clinic in the capital.

Now, if even the close family members of Malawi’s best trained and most motivated AIDS clinicians can die from accessing treatment too late, what does that mean for others? I know it is not the clinician’s fault in any way. But, in the abstract, this shows that the challenge of getting people into treatment, and into treatment on time, is not as simple as increasing knowledge about HIV and TB or improving access to care. As all of us in this profession understand, we have a long way to go in winning this battle. Sometimes, it feels like the war has barely started.