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AFRO-NETS> WHO and ARV access (3)

WHO and ARV access (3)
Dear Afro-netters!
I have been following the discussion on AFRO-NETS and around us about 
antiretroviral treatment (ART) with concern. Peter Burgess is "terri-
bly sceptical". I don't know what that makes me, maybe overwhelmingly 
sceptical. In the discussion of access to ART I haven't really seen 
any discussion about anything else but the cost of the medication / 
medicines itself. I think that most of the countries in desperate 
need for ART for their people can not afford ART even if the antiret-
rovirals are free. I really think that we should start to discuss 
about these problems and try to find solutions.
To treat people with HIV we have to test them first. For testing we 
need trained counsellors (for pre- and post-test counselling as well 
as continuous counselling). Training costs quite a lot and we need 
many many counsellors. The counsellors need to be employed. To treat 
people with HIV we need also to train doctors and nurses. Treatment 
is not simple, one protocol is good for one person, the other for the 
other one. Side-effects of the treatment may force the medication to 
be changed. This should only be done by a well trained health profes-
sional. In quite many counties there is lack of health professionals, 
so if we put doctors and nurses in charge of HIV-treatment, it might 
be difficult to find people to take care of their previous duties.
We have to identify people in need of medication. This could be done 
with CD4-cell counts (laboratory tests) or with clinical evaluation. 
Both of these methods are costly and have to be repeated about every 
6 months.
People with ART need regular controls and also some regular blood 
If a person gets side-effects of the medication and lives for example 
20 kilometres from the clinic, do we really believe that (s)he will 
walk to the clinic (when sick with diarrhoea for instance) and ask 
for some other kind of medication? Most probably (s)he will just stop 
the medication.
Very many - if not most - of the people with HIV are quite poorly 
educated or illiterate. If the treatment regimen is in any way com-
plicated (for instance one medicine should be taken twice daily and 
another one every 8 hours), this might be too difficult to carry out. 
And we are talking about medication for the rest of the person's 
Poverty is one of the main reasons HIV is so prevalent in Southern 
Africa for example. Poverty is also one of the reasons why implement-
ing ART might be very difficult. Let's assume that I am infected with 
HIV, my husband has left me and I live in a rural area in Namibia 
without any work which I would get paid for. If I get ART for one or 
two weeks and my children do not have food, I would most probably 
sell the medicine and buy food for my children. Also side-effects of 
the medication are more likely if I do not have proper food.
So, in my opinion the problems with ART are partly problems with the 
cost of the treatment (including training and employing counsellors, 
training and possible relocation of nurses and doctors, cost of HIV-
tests, cost of CD4-cell counts and other laboratory tests, cost of 
medicines) and partly problems with adherence to the treatment (dif-
ficult treatment protocols, side-effects, poverty) which create a 
substantial risk of short and ineffective treatment and thus a real 
risk of creating resistance.
I think that ignoring these problems and only concentrating on the 
price of the medicines gets us nowhere. When the medicines finally 
are affordable, we won't have the strategy to ensure that people in 
need get them.
Maija Palander
Medical Doctor, Project Manager
Windhoek, Namibia
Tel: +264-61-257-231
Fax: +264-61-257-216

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