February 2002 Insights Health Issue #2

Back to Insights Health #2

Delivering the goods:
HIV treatment for the poor

HIV has spread like wildfire, causing untold suffering and death and creating profound development challenges. Antiretroviral drugs (ARVs) are standard treatment for HIV in wealthy countries and should be included in a package of care for all infected people. Increasing access to HIV care and treatment requires immediate action. This should involve innovative use of existing health infrastructure with simplified approaches to treatment, long-term development of the health sector, greatly increased donor investment and government commitment.

An estimated 40 million people are infected with HIV and 16,000 new infections occur every day. Developing countries bear more than 90 percent of the global burden of HIV/AIDS, which threatens to undermine the development gains of recent decades. These countries face not only the immediate challenge of caring for people affected by HIV/AIDS, but also a long-term development crisis.

HIV causes AIDS by gradually destroying the body's immune system. This allows common infections such as tuberculosis (TB) to flourish, in addition to previously rare infections and tumours. HIV-related illnesses are frequently fatal when diagnostic and treatment facilities are limited.

The introduction of ARVs in the 1990s dramatically reduced illness and death among people with HIV in wealthy countries. Three or more ARVs taken in combination can reduce the amount of HIV in the blood. Immunity improves and patients start to get better. ARVs are also given as part of standard ante-natal care for HIV-infected mothers and their newborn babies in developed countries to reduce the risk of mother-to-child transmission.

Increasing access to ARVs in developing countries presents huge challenges. The first barrier is the cost of the drugs (at least $1000/person/month in wealthy countries). For a long time ARVs were beyond the reach of those living in poverty. However, international activism has led to dramatically reduced drug prices for developing countries.

The second major barrier is the lack of an adequate health infrastructure for drug delivery. ARVs are not a cure for HIV and must be taken for life. Wealthy countries take a highly technical and specialised approach, using frequent laboratory tests to monitor patients' immune status, drug side-effects and the development of drug resistance. HIV gradually becomes resistant to ARVs in all individuals taking them. New drug combinations are then required. Drug resistance develops more quickly if adherence is poor, i.e. when patients forget to take tablets regularly or take inadequate drug combinations. Drug-resistant HIV can then be transmitted to other people.

Care for people living with AIDS involves other important features, apart from ARVs, including:

• prevention of TB and other infections
• treatment of HIV-related illnesses
• pain relief
• treatment for sexually transmitted infections (STIs)
• prevention of further HIV spread (for example, by supplying condoms)
• family planning
• psychological support
• end-of-life care.

Most people do not have access to even these basic services. Therefore ARV delivery is part of a broader challenge to provide access to this whole package of interventions. The entry-point to comprehensive care is voluntary counselling and testing for HIV (VCT). Baggaley explains how good quality VCT provides many benefits in addition to diagnosis of HIV and bridges the gap between care and prevention. Clients derive support from counselling and gain entry to a range of HIV care interventions. VCT also prevents new HIV infections by encouraging sexual behaviour change. Taegtmeyer describes Kenya's initiative to ensure that VCT quality is maintained as services are scaled up. Hausler and Godfrey-Faussett discuss how pilot projects in South Africa have increased access to VCT and a package of HIV/STI/TB care and prevention services through the routine district health system.

But HIV care is costly. VCT services alone cost more per person than the annual per capita health expenditure of many developing countries. Despite falling drug prices, a year's supply of ARVs still costs more than the average annual income of many poor people. Nevertheless, Vitoria describes how Brazil's programme of universal access to ARVs, although costly, has produced overall health service savings. As demonstrated in Kumaranayake's article, providing such care in poorer countries will require unprecedented donor input and in-country government commitment. The new Global Health Fund for AIDS, TB and Malaria will hopefully provide an effective channel for increased support.

Provision of HIV care, including ARVs, requires both an 'emergency' response and a long-term 'development' response. An emergency response should aim to:

• relieve individual suffering
• enable people with HIV to remain productive for longer
• control ARV use to prevent drug resistance
• improve HIV prevention efforts
• provide hope and counter the stigma of HIV.

The 'development' approach includes addressing system-related factors that underlie general ill-health in developing countries, such as poverty and gender inequalities. Current health sector reforms seek to streamline health service provision, improving equity through decentralisation and introduction of sector-wide approaches. Many countries have embarked on these reforms, but improving services will take time. It will be many years before health systems in developing countries can apply the high-tech approach of wealthier countries. To rapidly increase access, HIV care and ARVs must be available through existing healthcare structures, despite their inadequacies.

Each country must decide at what level they will provide ARVs. Wilson reports on a pilot project in Thailand that supplies ARVs through district hospitals. This involves training and support for doctors and relatively sophisticated laboratory monitoring. Other countries may require a simpler approach. Clinical services in the poorest countries do not have enough nurses and paramedics. Hospital laboratories struggle to perform the simplest tests due to lack of functioning equipment, chemicals, and reliable water and electricity supplies. Until cheaper and more appropriate laboratory tests become available, health planners should devise and test ARV treatment protocols that allow monitoring based on the patients' symptoms and medical examination. Clear guidelines for management of side-effects are required.

In some countries the provision of HIV care and ARVs at district hospitals will only increase access to a limited degree. Dhaliwal discusses how the International HIV/AIDS Alliance, an NGO which supports and promotes community action on AIDS, has identified barriers to access to treatment and developed strategies to solve these problems. Patients may face similar barriers as those described by Squire, Salaniponi and Kemp for access to TB care in Malawi, where the per capita GNP is US$ 197 compared with US$ 3640 in Brazil. There are many parallels between the treatment of TB and HIV (see Box 1) and much can be learnt from TB control programmes.

Farmer and Koenig explain how existing community health infrastructure for TB treatment in Haiti was successfully used to deliver ARV beyond the hospital to the rural poor. Other countries should pilot similarly innovative approaches to HIV care using existing systems. Careful planning and priority setting must ensure that HIV care and ARVs are provided:

• whilst maintaining services for other common diseases
• without detracting from HIV prevention efforts
• in the most equitable way
• through existing services in the short-term, whilst planning and implementing increased access through long-term health sector reforms.

The design of the first phases of implementation should include a plan for scaling up to national coverage and should attempt to answer operational questions around the best ways of introducing HIV care and ARVs in resource-poor settings (see Box 2).

Nicola Hargreaves and Anthony Harries
Malawi National TB Control Programme
Community Health Sciences Unit
Private Bag 65
Lilongwe
Malawi

T: +265 754936

nicky@malawi.net
adharries@malawi.net

Back to Insights Health #2