Jump to content

HIV and AIDS

Demystifying antiretroviral therapy in resource-poor settings

Lessons for improving access to antiretrovirals in poor areas

Authors: ; Access to Essential Medicines Campaign: Médecins Sans Frontières (MSF)
Publisher: Access to Essential Medicines Campaign, MSF, 2003

Full text of document

This paper uses the example of a poor township 30 kilometres outside Cape Town to find out if antiretroviral therapy is possible in severely resource-constrained environments and to discover the best ways to deliver these drugs.

Zidovudine (AZT), first became available in Khayelitsha township’s two maternity wards in early 1999, and the programme has subsequently become one of the continent’s biggest. Treatment was initially limited to opportunistic infections, but in May 2001, this was broadened to include antiretroviral therapy (ART), making the project the first to use antiretrovirals in government health facilities outside the context of clinical trials.

In analysing the programme’s success to date and assessing the possibilities to use it as a model in other settings, three key aspects stand out:

  • the drugs must be affordable. In this case, it meant beginning with brand-name drugs which, although considerably cheaper than in developed countries (or, indeed, in South Africa a few years earlier), were still much more expensive than generic versions produced in countries such as Brazil, India and Thailand
  • the involvement of the community. This was facilitated by giving all treatment at primary health care level, rather than at a large reference hospital. The community was also integrally involved in the process of selecting patients for ART, which played a major role in guaranteeing local ownership over the project as a whole
  • the involvement of the patients themselves has been essential. They are genuine partners in the project at a number of levels:
    • the political level, when politicians have questioned the validity of using ART in resource-poor settings, it was the patients who responded, writing letters to newspapers and speaking out in the media
    • at the community level, they play an important role in the support groups run for patients on ART, with those who have been on therapy for longer periods of time helping mentor those beginning. Also, a number of patients work with a South African NGO, the Treatment Action Campaign, on a major community education initiative
    • at the individual level, patients have educated themselves on the importance of adherence, allowing them to take responsibility for their own therapy, making it unnecessary to use medical staff to observe them taking their pills

The project has revealed a number of important lessons:

  • ART can be safely and effectively used in resource-poor settings, and the time has come to scale up from pilot projects widespread access
  • Managing patients on ART is often easier than managing patients not taking antiretrovirals due to a lesser need to diagnose and treat opportunistic infections
  • The availability of ART bolsters the entire health system as it enables the staff’s role to shift back from care of the dying to being able to help patients return to good health, with an obvious improvement in morale
  • Access to ART has ensured retention of patients. In Khayelitsha, not a single patient on antiretroviral therapy has been lost to follow up, in marked contrast with the general experience in this highly mobile township
  • A considerable percentage of the costs incurred by drug purchases can be offset by drops in hospitalisations and opportunistic infections
  • In Khayelitsha, the availability of treatment has provided a powerful incentive to learn one’s status. Thus demonstrating the synergy between treatment and prevention