HIV and AIDS
Provision of antiretroviral therapy in resource-limited settings: a review of experience up to August 2003
Delivering effective treatment for HIV/AIDS in poor countries: impact, current approaches and issues for policy
Authors:
K. Attawell; J. Mundy; World Health Organization (WHO)
Publisher:
Department for International Development Health Systems Resource Centre , 2004
Cheaper drugs and increased levels of financing mean the prospects should be improving for people with HIV/AIDS in poorer countries. There has been an expansion of existing antiretroviral therapy (ART) programmes and a number of new initiatives. But how can access to ART be most effectively improved, and what are the pitfalls that policymakers must avoid? In this briefing paper DFID’s Health Systems Resource Centre gives an overview of experience to date and lessons learned.
The paper reviews whether ART is feasible in situations where resources are scarce, discusses the different approaches being adopted to providing ART in the public, NGO and private sectors, and sets out the issues involved in making it more widely available. The authors examine the issues of patient selection; health systems; clinical management; demand for and adherence to treatment regimes; community involvement; affordability and financing; and monitoring and evaluation. A lengthy executive summary is also provided.
- Several pilot studies demonstrate that highly active antiretroviral therapy (HAART) is feasible and effective in resource-poor settings. The impact in reducing mortality rates is variable, but provision of ART is associated with social and health benefits and cost savings.
- In middle and low-income countries, fewer than 1 in 18 people who would benefit from ART were actually receiving it in 2002, according to the WHO.
- HIV/AIDS is increasing demands on over-stretched systems and undermining the capacity of health systems to provide services.
- There are few examples of ART being integrated into existing HIV/AIDS prevention and care services.
- Widespread use of WHO clinical guidelines has resulted in simplified treatment programmes, thus keeping costs low and enabling more people to be treated. Work is continuing on developing new and cheaper technologies for laboratory testing/clinical monitoring.
- Uptake of and adherence to ARV can be affected by attitudes to the treatment; lack of financial resources; lack of transport; stigma and fear of discrimination.
- Despite lower prices and the availability of generic ARV drugs, treatment is still expensive. In May 2003 the lowest cost generic combination was just under US$300 per year.
The report highlights a number of policy-relevant findings regarding the structure and focus of ART programmes, priorities of investment and training, and financing issues. They include the following:
- Priority setting for scaling up ART programmes requires the setting of clear goals and targets. Global health initiatives can distort national priority-setting, planning and budgeting processes.
- Scaling up programmes is best achieved through collaboration between a mix of providers from public and private sector, NGO and community-based approaches. As programmes scale up, a number of equity issues must be considered.
- If investment is used to improve infrastructure, human resources and logistics, scaling up ART can strengthen health systems.
- Working with patients, their families and communities can help overcome barriers to accessing treatment. Appropriate training for health providers, and education and capacity building for communities are crucial to the success and sustainability of expanded ART programmes.
- Governments will continue to need external aid to provide free or highly subsidised ART. A multi-funding approach is needed, using a variety of financing strategies.
- Simple but effective monitoring and evaluation systems are needed that can be developed step-by-step and which do not add too much to existing workloads.
