Two Viewpoint articles in this week’s issue of THE LANCET highlight how the use of highly-active antiretroviral therapy (HAART) for HIV-1 treatment - currently only widely available in industrialised countries - could become accessible in less-developed settings. Both articles suggest new strategies for implementing HAART using infrastructure previously developed for tuberculosis control.
Last year, HIV surpassed other pathogens to become the world’s leading infectious cause of adult death. More than 90% of deaths occur in poor countries, although new antiretroviral therapies have led to a drop in AIDS deaths in industrialised countries. The main objections to the use of these agents in less-developed countries have been their high cost and the lack of health infrastructure necessary to use them.
Paul Farmer and colleagues from Harvard Medical School, Boston, USA, have shown that it is possible to run an HIV-1 treatment programme in a poor community in rural Haiti, the poorest country in the western hemisphere. Relying on an already existing tuberculosis-control infrastructure, the authors provided directly-observed therapy with HAART to about 60 patients with advanced HIV-1 disease. Inclusion criteria and clinical follow-up were based on basic laboratory data available in most rural clinics; serious side-effects were rare and were readily managed by community-health workers and clinic staff. The authors conclude that directly-observed therapy of chronic infectious disease with multidrug regimens can be highly effective in resource-poor settings as long as there is sustained commitment to uninterrupted care that is free to the patient.
A second article by Anthony Harries and colleagues from the National Tuberculosis Control Programme and National AIDS Control Programme, Malawi, calls for a similar approach in sub-saharan Africa-integrating an HIV strategy within existing tuberculosis-treatment infrastructure. The authors stress the importance of a coordinated approach for use of HAART to prevent the emergence of multidrug resistance to HIV-1 treatment.
Anthony Harries comments: "An antiretroviral programme would introduce the most advanced level of care for people with HIV and AIDS who in most countries are not receiving even the minimum standard. However, antiretroviral drugs are already being provided in many countries in a chaotic fashion. We believe that a structured system of antiretroviral provision is urgently needed in sub-Saharan Africa. If this is combined with an essential package of care, the lot of patients living with AIDS could improve and drug resistance curtailed."
Contact: Dr Paul Farmer, Department of Social Medicine,Harvard Medical School,641 Huntington Avenue,Boston MA 02115,USA;T)1-617-432-1707;F)1-617-432-2565;E) pefarmer@bics.bwh.harvard.edu
Professor Anthony D Harries, British High Commission,PO Box 30042,Lilongwe 3,Malawi;T) 265-754936; F) 265-772-657;E) adharries@malawi.net
Journal
The Lancet