Bicycles could hold the key to increasing HIV treatment access in Malawi

A study that examined how long Malawians need to travel to receive HIV treatment suggests long travel times in some rural areas, along with poor transport access, may stop the Malawian government from reaching its 90% treatment coverage goal.

Around 80% of Malawians live in rural areas, and many have to travel long distances to access healthcare. Transport is also scarce: only 2% of rural households have a car or truck and one in ten people own a bicycle. In 2019, 79% of people living with HIV in Malawi were on treatment, a figure that needs to rise to at least 90% by 2030 if the country is to meet UNAIDS’ 90% treatment coverage target.

Using geospatial modelling, researchers calculated the time it takes each person living with HIV in Malawi to travel for treatment, taking factors such as terrain and the state of roads into account.

It found large differences between rural and urban areas when it comes to accessing treatment. Travel time to reach a healthcare facility was less than one hour in urban or semi-urban areas, one to two hours in many rural areas, and up to four hours in remote rural areas.

On average, for those already accessing HIV treatment, healthcare facilities were found to be within 45 minutes drive, just over an hour’s bicycle ride (65 minutes) or a one-hour 25-minute walk.

But for some people living with HIV in rural areas who are not on treatment, travel times are almost twice as long. If these people want to access treatment, they will need to drive for up to 1.5 hours, cycle for up to 1.8 hours or walk for up to 2.2 hours. As these results are based on one-way travel only, some people living with HIV will need to walk for around 4.5 hours, round trip, if they are to access treatment. What's more, these estimates are based on the speeds of a healthy adult and do not take into consideration anyone who may be in poorer health, pregnant or travelling with children.  

These findings suggest that, unless addressed, long travel times and a lack of transport will continue to prevent some people living with HIV from accessing treatment. There may become a point when treatment coverage can no longer expand because of this, meaning this issue is likely to become increasingly important.

The study indicates that making bicycles available in some rural areas would help to increase coverage because this would make it more realistic for people to reach their closest clinic.

The study’s authors said: “UNAIDS has prioritised 22 countries in sub-Saharan Africa for fast-tracking the end of their HIV epidemic, including Malawi. Many of the prioritised countries have similar characteristics to Malawi, being predominantly rural, with limited healthcare infrastructure in rural areas, and with many people living with HIV having to walk to access treatment."

As most of these countries have already high levels of treatment coverage (70-75%), they may find geographic inaccessibility to healthcare and insufficient transportation in rural areas are major barriers to substantially increasing coverage. The authors noted that increasing the availability of bicycles could make reaching 90% treatment coverage more achievable.

In addition to bicycles, other creative solutions need to be explored to increase geographical accessibility to care. These include further decentralisation of health care, improved transportation, mobile clinics, drones for delivering medication, community medication groups (i.e., only one member of the community visits the clinics and collects medications for all people living with HIV in the community), and differentiated care initiatives.

The authors noted, "A single solution will not solve the problem; a combination of solutions is needed."