WHO and ARV access (6)
In response to the message from Maija Palander who responded to the
message from Peter Burgess.
>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. And we are talking
>about medication for the rest of the person's life........... etc.
I think we have become much more aware of the issues mentioned by
Maija and the need for comprehensive programs before provision of
treatment with ARV drugs can even be considered. For example, MSF has
been implementing successful comprehensive pilot treatment programs
in several countries. I would like to refer people to the Khayelitsha
program described in the latest edition of the Essential Drugs Moni-
tor as an example of how the important issues mentioned above are ad-
That is not the only example but the report is very succinct. The MSF
programs in Thailand, Kenya and other countries are all run along the
same lines. Patients must be admitted to the program. Counsellors are
in place. Follow-up is available etc. As well as clinical criteria
for admission to the program there are social criteria - patients
must have not missed an appointment for 4 months and have complied
totally with treatment for opportunistic infections. In addition they
must identify one person they disclose to for support. That person is
trained. It maybe a family member or not. That person helps support
the person's treatment and provides support for any problems or for
referral to the clinicians for clinical problems. This might sound
like discrimination. You would not demand all that for admission to
treatment for diabetes. But in this case success of treatment is so
crucial that I think it is justified.
A complete report of the Khayelitsha program will be released soon
and we will make it available.
The treatment programs run by companies such as Heineken are similar
and the DFID policy also covers those issues. Care of families and
criteria for lifelong support are built into the policies.
By the way, low cost appropriate technology CD4 tests and training
are being provided in many countries. These tests rely on humans and
buckets rather than a lot of hightech electronic equipment and com-
puters. Comparison studies have checked that the results correlate
well with the results obtained by the hightech methods and they do.
Tests are around US$ 6 each at the moment and price is less for bulk
orders. Prices are likely to reduce more anyway.
The Haiti program described by Paul Farmer et al in Lancet Vol. 358
Aug 4, 2001 - 'Community based approaches to HIV treatment in re-
source-poor settings' - relies on clinical criteria rather than lab
criteria for admission to the treatment program.
If people would like more information about the programs I have men-
tioned please contact me.
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