Travel time to health-care facilities and HIV elimination in Malawi
Authors: Sam Phiri, Christine Kiruthu Kamamia
Journal: The Lancet Global Health (2020)

HIV has had a devastating effect on Malawi, where the prevalence stood at 9% among those aged 15–49 years in 2018.1UNAIDSMalawi overview.https://www.unaids.org/en/regionscountries/countries/malawi#:~:text=There%20has%20been%20progress%20in,000%20in%20the%20same%20periodDate accessed: August 17, 2020Google Scholar Still, the landlocked country has made great strides within the past decade to achieve the ambitious UNAIDS 90-90-90 targets (90% of all people living with HIV knowing their HIV status, 90% of all people with diagnosed HIV infection receiving sustained antiretroviral therapy, and 90% of all people receiving antiretroviral therapy having viral suppression). Malawi has implemented several strategies to control the epidemic and reduce the overall mortality by 55% from 29 000 deaths in 2010 to 13 000 deaths in 2018.1UNAIDSMalawi overview.https://www.unaids.org/en/regionscountries/countries/malawi#:~:text=There%20has%20been%20progress%20in,000%20in%20the%20same%20periodDate accessed: August 17, 2020Google Scholar As the country moves towards the 90-90-90 targets and gains are increasingly harder to achieve, novel approaches are continuously needed to reach the targets. In The Lancet Global Health, Laurence Palk and colleagues2Palk L Okano JT Dullie L Blower S Travel time to health-care facilities, mode of transportation, and HIV elimination in Malawi: a geospatial modelling analysis.Lancet Glob Health. 2020; 8: e1555-e1564Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar aimed to understand the role of distance to health-care facilities and the effect on HIV care and treatment coverage. The study is the first of its kind to suggest that travel time can be a substantial barrier to reaching epidemic control. The authors used a multi-pronged geospatial analysis—using a health-care infrastructure map, a density of infection map, and a friction-surface raster map—to comprehensively estimate the travel time of patients with HIV to health-care facilities across the country using different modes of transport. Palk and colleagues'2Palk L Okano JT Dullie L Blower S Travel time to health-care facilities, mode of transportation, and HIV elimination in Malawi: a geospatial modelling analysis.Lancet Glob Health. 2020; 8: e1555-e1564Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar model estimates that, at the existing level of antiretroviral treatment coverage of roughly 70%, people living with HIV who drive can reach a health-care facility within 45 min, those who bicycle can reach a facility within 1 h, and those who have to walk can reach one within 1·5 h. As coverage increases, these intervals become longer because people living with HIV from rural and remote areas need access to a health-care facility. At a coverage of the UNAIDS target of 90%, using the authors' model would mean that these travel intervals will increase to approximately 1·5 h for those travelling by car, 1·8 h for those on bicycles, and those who walk will need to travel for up to 2·2 h. Another way to assess the analysis is to estimate what proportion of people living with HIV could reach a health-care facility if they needed to travel for a maximum of 1 h. At the national level, 80% coverage would be possible if all three modes of transport were available, dropping to 65% if only bicycles and walking were available, and to 50% if all people living with HIV had to walk. Limited to access to transportation in rural areas in Malawi is a major barrier to achieving high coverage levels, which would be improved by the availability of bicycles. Although the study findings are important and highly welcomed, these findings do not address other factors that affect transportation and access to care. The study did not account for the physical ability of patients to travel or weather conditions, both of which substantially affect travel time and even the ability to reach the clinic. Other known limitations are the interruption of services at health-care facilities, including stockouts, which have a substantial effect on the care that the patient will receive. Proximity to a health-care facility does not affect the quality of care available at the facility, which is why some people living with HIV choose to travel to a higher-tier facility even if the facility is not the nearest.3Akullian AN Mukose A Levine GA Babigumira JB People living with HIV travel farther to access healthcare: a population-based geographic analysis from rural Uganda.J Int AIDS Soc. 2016; 1920171Crossref PubMed Scopus (35) Google Scholar However, the study has important policy implications, as noted by the authors.2Palk L Okano JT Dullie L Blower S Travel time to health-care facilities, mode of transportation, and HIV elimination in Malawi: a geospatial modelling analysis.Lancet Glob Health. 2020; 8: e1555-e1564Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar The Malawian Government estimates that 90% of the population lives within 8 km of a health-care facility.4Malawi Ministry of Health and PopulationHealth care system.https://www.health.gov.mw/index.php/2016-01-06-19-58-23/national-aidsDate accessed: August 17, 2020Google Scholar Malawi, like other sub-Saharan African countries, has a serious health worker shortage. The density of health workers to patients is 0·019 physicians, and 0·283 nurses per 1000 population, which is much lower than the WHO recommendation of at least 2·28 doctors and nurses per 1000 population.5Bickton FM Lillie T Strengthening human resources for health in resource-limited countries: the case of medic to medic in Malawi.Malawi Med J. 2019; 31: 99-101Crossref PubMed Scopus (2) Google Scholar Access to care and quality of care need to move hand-in-hand in ensuring adequate coverage to all people living with HIV. Although increasing the number of health-care facilities across the country is desirable, doing so requires expanding the health-care workforce to serve the country adequately. This study's findings can be used to guide strategic thinking on how to increase access to care and quality care to rural and other hard-to-reach areas. The Malawi HIV programme has taken several measures to achieve the UNAIDS 90-90-90 targets by using novel approaches to test hard-to-reach populations such as the use of index testing or self-test kits. Additionally, the country has successfully undertaken the expansion of differentiated care models by delivering tailored care to serve the needs people living with HIV better while unburdening the health systems. These include enhanced adolescent clinic days for individuals aged 10–19 years, where tailored comprehensive clinical and psychological care is provided; community delivery of antiretroviral therapy; dispensing of multiple months' worth of antiretroviral drugs at a single visit; and advanced HIV disease care. These factors have all contributed to controlling the epidemic. Palk and colleagues' study2Palk L Okano JT Dullie L Blower S Travel time to health-care facilities, mode of transportation, and HIV elimination in Malawi: a geospatial modelling analysis.Lancet Glob Health. 2020; 8: e1555-e1564Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar emphasises the need to implement targeted interventions to reach people living with HIV in rural areas where the yield might be lower, but where patients face more challenges in accessing care than their counterparts in urban areas do. Increasing the number of people living with HIV who bicycle and live in rural areas could indeed be another useful step to expand coverage to people living with HIV in rural areas, and thus reach part of the remaining population struggling to achieve coverage. In parallel, such measures might provide economic opportunities that would positively affect people living with HIV. We declare no competing interests. Travel time to health-care facilities, mode of transportation, and HIV elimination in Malawi: a geospatial modelling analysisThe long travel times needed to reach health-care facilities coupled with little motorised transportation in rural areas are substantial barriers to reaching 90% coverage in Malawi. Increased bicycle availability could help eliminate HIV. Full-Text PDF Open Access