On My Way to Malawi

Somewhere in the Air

I just left San Francisco International Airport aboard a United Airlines jet and am now somewhere high above California as I begin my 36-hour journey to Malawi. I am traveling alone on the first leg of the trip from San Francisco to Frankfurt, Germany. The plan is to meet with Dr. Sally Rankin in Germany, and we will travel the rest of the trip together. Dr. Rankin is the principal investigator of the National Institutes of Health (NIH) R01 parent grant and my mentor, and I am the principal investigator of a 2-year research project diversity supplement grant from the NIH.

The overall purpose of the parent grant is to study the role of 5 religious organizations in Malawi's struggle against HIV/AIDS: Baptist (BACOMA), Muslim (MUWO), Living Waters (LW), Roman Catholic (RC) and Anglican (ANG). My project will look specifically at strategies used by these organizations and by traditional healers to help people living with HIV/AIDS (PLWHA) access antiretroviral (ARV) medicines. I will also look at barriers to treatment and care faced by those infected.

A Bit of Background

A Bit of Background
In order to better understand my reports as I gather data in Malawi, some background on HIV/AIDS in Malawi is in order.

Role of Religious Organizations
The role of Malawi's religious organizations in HIV/AIDS prevention and care is poorly understood within the broader context of Africa's many blended cultures and behaviors. Sub-Saharan African family life and community life are very intertwined with religious life, therefore religious groups, whether they are a fusion of many beliefs or follow a single doctrine, influence HIV-related beliefs and practices.

Religious organizations most often provide the only infrastructures reaching rural areas, where the majority of Malawian people live. Approximately 55% of Malawians are Protestant, 20% are Roman Catholics, 20% or fewer are Muslim, and 5% practice African traditional religions. Religious leaders are frequently accorded respect as opinion-leaders in their communities.

In religious ceremonies, leaders have a public platform from which to challenge destructive prejudices that reinforces stigma, while conveying important information concerning HIV prevention and care. Limited data are available that characterizes how churches provide health information on the care and treatment of people infected with the HIV virus or tangible resources to assist members with costs of transportation, medical care, food, and medications.

The HIV/AIDS Crisis
900,000 Malawians were living with HIV/AIDS at the end of 2003, with 90% of all infections falling within the 15 to 49 age range (810,000 people). The effects of HIV/AIDS on Malawi’s population can be seen in declining life expectancy at birth, which in 2004 was 38 years.

Healthcare and ARV Access
Access to healthcare has impacted the nation’s ability to respond to the epidemic. A 1998 report estimated that 81% of Malawi’s urban population had access to health care services, but only 29% of rural people had such access. A new issue in Malawi is the problem of accessibility and affordability of ARVs that became available during the summer of 2004. Most PLWHA in Malawi are unable to afford medications through private sources and are thus dependent on the free ARVs that are available in 59 hospitals and district clinics. As of July 2005, only 18,000 of the 170,000 HIV-positive men, women, and children who need ARVs are receiving them, primarily through the Ministry of Health’s rollout program to provide free ARVs. In light of the efforts to scale-up distribution of free ARVs, access issues have become an important subject of debate and discussion. PLWHA in need of ARV therapy face the difficult challenge of not having transportation to the hospitals and district clinics that dispense ARVs. Parents who wish to access ARVs for their infected children are presented with obstacles of not having available medications in appropriate pediatric formulations. ARVs that require refrigeration are problematic since 2% of rural households have electricity. Food security plays a significant role because patients often do not have food to take along with the ARV medicines.

Our Project

Within this context, we have set out to learn and describe how religious leaders and traditional healers help people living with HIV/AIDS access antiretroviral (ARV) medicines. This knowledge, in turn, will help to inform future interventions as different groups integrate their activities to help people access ARVs. Ours is a qualitative study using one-time individual interviews. We will be interviewing religious leaders, traditional healers, and PLWHA in rural villages and townships surrounding Blantyre and Zomba, which are in the south central region of Malawi.

Why Me?

Prior to joining the UCSF School of Pharmacy, I worked for 16 years as a clinical pharmacist providing medication information and education to patients in the acute and ambulatory care settings. These experiences then and now have shaped my career goal to become an independent investigator conducting research in the area of racial/ethnic and socioeconomic disparities in health as they relate to medication access and adherence. Currently these topics are of high importance and debate in the United States and worldwide. In 2005, I received a master’s degree in public health, which gave me a broader perspective and understanding of how to provide health information and education to community-based populations and how I as a pharmacist can integrate my unique expertise as a clinician and drug expert in these efforts.

In 2002, I became a member of the Board of Trustees of Global AIDS Interfaith Alliance (GAIA), a non-profit organization that raises funds for HIV/AIDS education and prevention programs in Malawi. We also provide for home-based care for Malawians with HIV/AIDS, orphan care, and women empowerment programs. In my first two trips to Malawi (2002 & 2004) I went in the role of a trustee member. Now in 2006, I am here as a researcher.

Being a part of an inter-professional research team is rewarding. It brings together a variety of perspectives that enrich the research process. I do believe that pharmacists have an important role in assisting patients define and solve problems related to medication access and adherence worldwide. Through this project I hope to enhance my qualitative and quantitative research skills, gain more insight on how to best design and conduct research studied, and eventually develop and test interventions that will improve the processes to access and adherence to medications.

This project is my first opportunity to be involved in international research in Africa. The knowledge we gain will have implications that cross all borders, and I am delighted and honored to be a part of this important work.