February 2002 Insights
Health Issue #2
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Demanding control
HIV treatment in Haiti
A growing number
of people in poor countries need effective HIV therapy. Despite the
potential problems of cost and drug resistance, this demand will not
go away. Falling drug prices mean that patients will have increasing
access to antiretroviral drugs (ARVs). The degree to which we control
their use is a key challenge for public health policy.
The US-based charity,
Partners In Health, works with local partners to provide ARV treatment
for more than 100 patients with advanced AIDS in rural Haiti. Over the
past decade, their programme has developed culturally appropriate prevention
tools, offered prenatal HIV testing and treatment, and provided post-exposure
treatment to people at risk from HIV due to rape or injuries from contaminated
needles. The infrastructure involved is largely human: community health
workers who have delivered directly observed therapy to tuberculosis
(TB) patients for many years.
Their recent experience
with the treatment programme has shown that:
- ARVs can produce
excellent results in resource-poor settings.
- The local TB-control
infrastructure can be adapted to provide directly observed therapy
for AIDS.
- Direct observation
enhances control of ARVs, improving clinical outcomes and limiting
the development of drug resistance.
- Providing social
services for people with HIV and their families further enhances adherence.
- The addition
of treatment services reinvigorates flagging HIV prevention programmes
and boosts staff morale.
- Providing effective
therapy for AIDS can reduce stigma, improve patients' quality of life
and further enhance prevention efforts.
Scaling-up is often
a challenge for small projects like this one. Funding for interventions
deemed 'cost-ineffective' is scarce. However, tackling AIDS and drug-resistant
TB requires complex health interventions in resource-poor settings.
The logic of cost-effectiveness will not provide solutions to the problems
posed by HIV among the poor. The implications for policy include:
- ARVs can and
will be used effectively in resource-poor settings. Policy-makers
should aim to improve control of these drugs whilst working for increased
access for the poor.
- Direct observation
can be incorporated into HIV treatment programmes.
- Reducing drug
prices, through concession or competition, will not solve the problem
of the destitute sick. Financing mechanisms must leave these drugs
under the control of the public health infrastructure and free of
charge to poor patients.
Paul
Farmer and Serena
Koenig
Partners In Health
641 Huntington Avenue
Boston MA 02115
USA
www.pih.org
pihpaul@aol.com
serena_koenig@hms.harvard.edu
See also
"Community-based approaches to HIV treatment in resource-poor settings"
by P. Farmer et al., The Lancet 358 (2001)
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