Barriers to better care for people with AIDS in developing countries
http://www.100md.com
《英国医生杂志》
1 Public Health GIS Unit, School for Health and Related Research, University of Sheffield, Sheffield S1 4DA, 2 School of Health Studies, University of Bradford, Bradford, 3 Centre de Recherche Cultures, Santé, Sociétés, Université d'Aix-Marseille, Maison Méditerranéenne des Sciences de l'Homme, 13094 Aix en Provence Cedex 2, France, 4 Uganda Red Cross Society, PO Box 494, Kampala, Uganda
Correspondence to: A S Furber A.Furber@sheffield.ac.uk
WHO's "3 by 5" initiative to increase access to antiretroviral drugs to people with AIDS in developing countries is highly ambitious. Some of the biggest obstacles relate to delivering care
Introduction
Ideally, care for people with AIDS should start with voluntary counselling and HIV testing. However, only 10% of people who need testing in low and middle income countries have access to services, and therefore most are unaware of their serological status.w5 Care should include psychological, social, and economic support as well as broad based medical care incorporating nutritional advice, prevention and treatment of opportunistic infections, and palliative care.3 w6 In many countries, this continuum remains to be set up.
The 3 by 5 initiative considers access to antiretroviral drugs as an opportunity to improve care and enhance prevention efforts.4 However, the focus on antiretroviral drugs risks distracting resources and attention from a broader model of health care. A recent survey of palliative care for people with AIDS in developing countries showed that services were often inadequate.5 Pain management was especially poor. India's decision to rapidly provide free antiretroviral drugs to 100 000 people with AIDS in the six states with the highest HIV prevalence created considerable debate, partly for this reason.6 7
Credit: FRIEDRICH STARK/STILL PICTURES
Countries need to take the opportunities presented by the WHO initiative to improve their public health infrastructure. Care for patients who do not require antiretroviral drugs is based on regular clinical follow up. But this kind of care, related to a chronic disease model, is far from the acute disease model presently dominant in the healthcare services of developing countries.8 Setting up this new model requires equipment, human resources, data management, and the use of communication tools that are both efficient and protect confidentiality.
Stigma and discrimination
Although the 3 by 5 initiative has already brought some important technical advances, such as the development of simplified treatment regimens and monitoring protocols,13 some issues related to the delivery of antiretroviral drugs remain. Some experts have argued that the best way to deliver highly active antiretroviral drugs treatment (HAART) is likely to be through directly observed therapy (DOT), so called DOTHAART,w11 in order to support adherence.
Lessons need to be learnt from the use of DOTs in tuberculosis.14 Although most developing countries have adopted DOTs for tuberculosis, and some have seen apparent successes,15 not all randomised controlled trials show that DOTs confer benefit.w12 w13 Experience in Africa has been highly variable.16 Treatment completion rates vary from 37% (low) in the Central African Republic to 78% (moderate) in Kenya and Tanzania. Clearly multiple approaches to delivering antiretroviral drugs will be required to close such gaps.
Senegal, Malawi, and South Africa have achieved high and sustainable adherence rates for antiretroviral drugs without directly observed treatment.17 w4 The important factors seem to be the regular supply of medicines, efficient health service management, and support through "antiretroviral drugs literacy promotion" and self support groups.
As the quality of life for patients on antiretroviral drugs improves, frequent contact with healthcare providers may be difficult. In Dakar, missing monthly appointments to obtain antiretroviral drugs was the first reason for non-compliance among patients in their second year of treatment.w14 Most patients had returned to their jobs, often requiring stays far from home, especially for sailors and retailers. A visit to the hospital to obtain antiretroviral drugs often takes several hours, which is inconvenient for all patients.
Community involvement
Concern has been voiced that existing criteria for access are inequitable.18 Presently most programmes providing treatment do so at different tariffs based on different ways of considering equity. A patient who gets free treatment in one programme might be asked for a payment in excess of average monthly wages in a neighbouring programme. Providing free or subsidised treatment on a first come, first served basis tends to favour richer, urban, and more educated people. Perversely, these are the people in whom treatment might be least effective as many of them will have previously purchased antiretroviral drugs through private facilities. Leaving decisions about charges to front line staff leads to inconsistencies and may lead to corruption.
Criteria for access to subsidised antiretroviral drugs in national programmes differ substantially between countries. In West Africa, these criteria are based on social characteristics, level of income, profession, social status, and number of dependants.w19 Perceptions of equity differ at local levels, often related to a community's social dynamics. Such variation is difficult to manage from both a public health and a clinical perspective and doesn't fulfil requirements for equity at national or international levels.
Introducing user charges is likely to be inequitable as well as adversely affecting adherence.18 19 Many families will already be living in poverty as a result of a reduction in income or paying for AIDS care. Providing free access to antiretroviral drugs based on rights and not ability to pay,19 as occurs in the Senegal national programme, will be most equitable, will resolve dilemmas over the treatment of migrants, and will also reduce migration to obtain antiretroviral drugs.
Conclusions
Mukherjee JS, Farmer PE, Niyizonkiza D, McCorkle L, Vanderwarker C, Teixeira P, et al. Tackling HIV in resource poor countries. BMJ 2003;327: 1104-6.
Word Health Organization. Treating 3 million by 2005: making it happen. Geneva: WHO, 2003. www.who.int/3by5/en/ (accessed 15 Dec 03).
Osborne CM, van Praag E, Jackson H. Models of care for patients with HIV/AIDS. AIDS 1997;11B: 135-41.
Gayle H, Lange JM. Seizing the opportunity to capitalise on growing access to HIV treatment to expand HIV prevention. Lancet 2004;364: 6-8.
Harding R, Stewart K, Marconi K, O'Neill JF, Higginson IJ. Current HIV/AIDS end-of-life care in sub-Saharan Africa: a survey of models, services, challenges and priorities. BMC Public Health 2003;3: 33.
Kumar S. India's treatment programme for AIDS is premature. BMJ 2004;328: 70.
Sharma DC. India unprepared for antiretroviral treatment plan. Lancet 2003;362: 1988.
Kitahata MM, Tegger MK, Wagner EH, Holmes KK. Comprehensive health care for people infected with HIV in developing countries. BMJ 2002;325: 954-7.
Parker R, Aggleton P. HIV and AIDS related stigma and discrimination: a conceptual framework and implications for action. Soc Sci Med 2003;57: 13-24.
Stanley LD. Transforming AIDS: the moral management of stigmatized identity. Anthropol Med 1999;6: 103-20.
Goffman E. Stigma: notes on the management of spoiled identity. Englewood Cliffs, NJ: Prentice-Hall, 1963.
Holmes W. 3 by 5, but at what cost? Lancet 2004;363: 1072-3.
World Health Organization. Scaling up antiretroviral therapy in resource-limited setting: treatment guidelines for a public health approach. Geneva: WHO, 2003.
Gupta R, Irwin A, Raviglione MC, Kim JY. Scaling-up treatment for HIV/AIDS: lessons learned from multidrug-resistant tuberculosis. Lancet 2004;363: 320-4.
China Tuberculosis Control Collaboration. The effect of tuberculosis control in China. Lancet 2004;364: 417-22.
Stevens W, Kaye S, Corrah T. Antiretroviral therapy in Africa. BMJ 2004;328: 280-2.
Lanièce I, Ciss M, Desclaux A, Diop K, Mbodj F, Ndiaye B, et al. Adherence to HAART and its principal determinants in a cohort of Senegalese adults. AIDS 2003;7(suppl 3): S103-8.
Loewenson R, McCoy D. Access to antiretroviral treatment in Africa. BMJ 2004;328: 241-2.
Mukherjee J. Basing treatment on rights rather than ability to pay: 3 by 5. Lancet 2004;363: 1071-2.(Andrew S Furber, clinical)
Correspondence to: A S Furber A.Furber@sheffield.ac.uk
WHO's "3 by 5" initiative to increase access to antiretroviral drugs to people with AIDS in developing countries is highly ambitious. Some of the biggest obstacles relate to delivering care
Introduction
Ideally, care for people with AIDS should start with voluntary counselling and HIV testing. However, only 10% of people who need testing in low and middle income countries have access to services, and therefore most are unaware of their serological status.w5 Care should include psychological, social, and economic support as well as broad based medical care incorporating nutritional advice, prevention and treatment of opportunistic infections, and palliative care.3 w6 In many countries, this continuum remains to be set up.
The 3 by 5 initiative considers access to antiretroviral drugs as an opportunity to improve care and enhance prevention efforts.4 However, the focus on antiretroviral drugs risks distracting resources and attention from a broader model of health care. A recent survey of palliative care for people with AIDS in developing countries showed that services were often inadequate.5 Pain management was especially poor. India's decision to rapidly provide free antiretroviral drugs to 100 000 people with AIDS in the six states with the highest HIV prevalence created considerable debate, partly for this reason.6 7
Credit: FRIEDRICH STARK/STILL PICTURES
Countries need to take the opportunities presented by the WHO initiative to improve their public health infrastructure. Care for patients who do not require antiretroviral drugs is based on regular clinical follow up. But this kind of care, related to a chronic disease model, is far from the acute disease model presently dominant in the healthcare services of developing countries.8 Setting up this new model requires equipment, human resources, data management, and the use of communication tools that are both efficient and protect confidentiality.
Stigma and discrimination
Although the 3 by 5 initiative has already brought some important technical advances, such as the development of simplified treatment regimens and monitoring protocols,13 some issues related to the delivery of antiretroviral drugs remain. Some experts have argued that the best way to deliver highly active antiretroviral drugs treatment (HAART) is likely to be through directly observed therapy (DOT), so called DOTHAART,w11 in order to support adherence.
Lessons need to be learnt from the use of DOTs in tuberculosis.14 Although most developing countries have adopted DOTs for tuberculosis, and some have seen apparent successes,15 not all randomised controlled trials show that DOTs confer benefit.w12 w13 Experience in Africa has been highly variable.16 Treatment completion rates vary from 37% (low) in the Central African Republic to 78% (moderate) in Kenya and Tanzania. Clearly multiple approaches to delivering antiretroviral drugs will be required to close such gaps.
Senegal, Malawi, and South Africa have achieved high and sustainable adherence rates for antiretroviral drugs without directly observed treatment.17 w4 The important factors seem to be the regular supply of medicines, efficient health service management, and support through "antiretroviral drugs literacy promotion" and self support groups.
As the quality of life for patients on antiretroviral drugs improves, frequent contact with healthcare providers may be difficult. In Dakar, missing monthly appointments to obtain antiretroviral drugs was the first reason for non-compliance among patients in their second year of treatment.w14 Most patients had returned to their jobs, often requiring stays far from home, especially for sailors and retailers. A visit to the hospital to obtain antiretroviral drugs often takes several hours, which is inconvenient for all patients.
Community involvement
Concern has been voiced that existing criteria for access are inequitable.18 Presently most programmes providing treatment do so at different tariffs based on different ways of considering equity. A patient who gets free treatment in one programme might be asked for a payment in excess of average monthly wages in a neighbouring programme. Providing free or subsidised treatment on a first come, first served basis tends to favour richer, urban, and more educated people. Perversely, these are the people in whom treatment might be least effective as many of them will have previously purchased antiretroviral drugs through private facilities. Leaving decisions about charges to front line staff leads to inconsistencies and may lead to corruption.
Criteria for access to subsidised antiretroviral drugs in national programmes differ substantially between countries. In West Africa, these criteria are based on social characteristics, level of income, profession, social status, and number of dependants.w19 Perceptions of equity differ at local levels, often related to a community's social dynamics. Such variation is difficult to manage from both a public health and a clinical perspective and doesn't fulfil requirements for equity at national or international levels.
Introducing user charges is likely to be inequitable as well as adversely affecting adherence.18 19 Many families will already be living in poverty as a result of a reduction in income or paying for AIDS care. Providing free access to antiretroviral drugs based on rights and not ability to pay,19 as occurs in the Senegal national programme, will be most equitable, will resolve dilemmas over the treatment of migrants, and will also reduce migration to obtain antiretroviral drugs.
Conclusions
Mukherjee JS, Farmer PE, Niyizonkiza D, McCorkle L, Vanderwarker C, Teixeira P, et al. Tackling HIV in resource poor countries. BMJ 2003;327: 1104-6.
Word Health Organization. Treating 3 million by 2005: making it happen. Geneva: WHO, 2003. www.who.int/3by5/en/ (accessed 15 Dec 03).
Osborne CM, van Praag E, Jackson H. Models of care for patients with HIV/AIDS. AIDS 1997;11B: 135-41.
Gayle H, Lange JM. Seizing the opportunity to capitalise on growing access to HIV treatment to expand HIV prevention. Lancet 2004;364: 6-8.
Harding R, Stewart K, Marconi K, O'Neill JF, Higginson IJ. Current HIV/AIDS end-of-life care in sub-Saharan Africa: a survey of models, services, challenges and priorities. BMC Public Health 2003;3: 33.
Kumar S. India's treatment programme for AIDS is premature. BMJ 2004;328: 70.
Sharma DC. India unprepared for antiretroviral treatment plan. Lancet 2003;362: 1988.
Kitahata MM, Tegger MK, Wagner EH, Holmes KK. Comprehensive health care for people infected with HIV in developing countries. BMJ 2002;325: 954-7.
Parker R, Aggleton P. HIV and AIDS related stigma and discrimination: a conceptual framework and implications for action. Soc Sci Med 2003;57: 13-24.
Stanley LD. Transforming AIDS: the moral management of stigmatized identity. Anthropol Med 1999;6: 103-20.
Goffman E. Stigma: notes on the management of spoiled identity. Englewood Cliffs, NJ: Prentice-Hall, 1963.
Holmes W. 3 by 5, but at what cost? Lancet 2004;363: 1072-3.
World Health Organization. Scaling up antiretroviral therapy in resource-limited setting: treatment guidelines for a public health approach. Geneva: WHO, 2003.
Gupta R, Irwin A, Raviglione MC, Kim JY. Scaling-up treatment for HIV/AIDS: lessons learned from multidrug-resistant tuberculosis. Lancet 2004;363: 320-4.
China Tuberculosis Control Collaboration. The effect of tuberculosis control in China. Lancet 2004;364: 417-22.
Stevens W, Kaye S, Corrah T. Antiretroviral therapy in Africa. BMJ 2004;328: 280-2.
Lanièce I, Ciss M, Desclaux A, Diop K, Mbodj F, Ndiaye B, et al. Adherence to HAART and its principal determinants in a cohort of Senegalese adults. AIDS 2003;7(suppl 3): S103-8.
Loewenson R, McCoy D. Access to antiretroviral treatment in Africa. BMJ 2004;328: 241-2.
Mukherjee J. Basing treatment on rights rather than ability to pay: 3 by 5. Lancet 2004;363: 1071-2.(Andrew S Furber, clinical)