Monitoring HIV treatment in developing countries

Abstract

Need for simplified short term strategies Human resources and healthcare infrastructures are severely limited in many of the countries that bear the greatest burden of HIV disease. We need to strike a balance between building systems for delivering antiretroviral drugs and investing in laboratory infrastructures to monitor treatment outcomes. In the short term, widespread implementation of antiretroviral drug programmes will be threatened if governments and providers in resource poor settings are required to follow the monitoring protocols currently used in middle and high income countries, which are costly and require vast human resources. After years of inadequate funding, the health systems in most developing countries have poorly functioning medical facilities, unreliable drug procurement systems, and a limited supply of essential medicines. In addition, most countries face a crisis in human resources, with insufficient numbers of healthcare providers, a problem that has been exacerbated by the high rate of HIV infection among doctors and nurses. Even relatively simple procedures widely used to monitor drug safety (such as routine tests of hepatic function) are not yet widely available in resource poor settings. Acknowledging this state of affairs in its current guidelines for HIV treatment in resource poor settings, the World Health Organization indicates that it “recognizes the importance of laboratory monitoring for efficacy and safety but does not want restricted infrastructure for these tests to place undue limitations on the scale-up effort.”4 Waiting for HIV drugs in Port-au-Prince Credit: AP PHOTO/ARIANA CUBILLAS Although advocating for different standards of care in industrialised and developing countries seems to perpetuate the inequalities that we are attempting to redress, the focus of our argument is the feasibility and public health benefits of immediately implementing widespread access to antiretroviral drugs, even in the absence of extensive laboratory capacity. Furthermore, clinical monitoring and close supervision of care—with community health workers making daily home visits, for example—can produce outcomes similar to those achieved in many US cities.5–7 Scarce human and financial resources must be augmented and, in the short term, deployed to focus on urgent and coordinated provision of basic health services, prevention and treatment of opportunistic infections, and expansion of access to antiretroviral drugs. Effective strategies must be developed to procure and distribute medications, train technical staff in the diagnosis and clinical management of HIV and AIDS, build systems to ensure patient adherence, and monitor and evaluate programmes. It is also essential that HIV prevention activities such as community education and condom promotion are strengthened to avoid a possible increase in HIV transmission as patients' lives are extended, potentially without complete suppression of the virus. Other ongoing critical health needs (tuberculosis control, clean water supply, vaccination and women's health programmes, nutritional support, etc) must also be tackled.7 Investing in AIDS prevention and care in this manner strengthens primary health care, as has been shown in Haiti.8