Introduction

Highly active antiretroviral therapy (HAART) must be expanded in sub-Saharan Africa, where the HIV/AIDS epidemic is taking an appalling toll. Malawi, a small, poor African country, is expanding HAART nationally. The “directly observed treatment, short course” (DOTS) strategy has been successfully used for years to provide effective national control of tuberculosis, and the same concepts are being applied for delivering HAART. We describe how the principles of standardised case finding, standardised treatment regimens, regular monitoring and evaluation, and uninterrupted supplies of drugs can be used to deliver HAART. If implemented well, these principles should ensure a controlled delivery system, which would reduce the risks of inconsistent prescribing practices and the development of drug resistance.

Response to Malawi's HIV/AIDS epidemic

In 2003 sub-Saharan Africa had an estimated 3.4 million new cases of HIV infection and up to 2.4 million deaths.1 Malawi has one of the highest HIV/AIDS prevalence rates in sub-Saharan Africa, with 14% of those aged 15-49 years infected.2 In 2003 an estimated 900 000 people had HIV/AIDS and about 86 000 died from AIDS related illnesses. AIDS is killing young adults in their most productive years, retarding development, producing a huge orphan population, and creating the foundations for political instability.

HAART has dramatically improved the survival of patients with HIV/AIDS in developed countries,3 4 where AIDS is now regarded as a potentially treatable and chronic condition rather than a fatal disease. In Malawi 170 000 people are estimated to need HAART.2 A countrywide survey by the Ministry of Health, however, found that just over 4000 people had started on …