Simplified, high-quality public health initiatives needed

Innovative community-based public health initiatives are needed to enable the rapid rollout of HIV/AIDS treatment in Africa, the World Health Organisation (WHO) director of HIV/AIDS, Jim Yong Kim, told PlusNews on Tuesday. To reach WHO's '3 by 5' goal (three million people on treatment by 2005) "simplified, high- quality public health initiatives are needed", Kim said at the 15th International AIDS Conference in Bangkok, Thailand. "There needs to be an attitude of learning by doing." The 3 by 5 initiative, launched by WHO in 2003, was a strategy to "energise" what has been a painfully slow rollout of antiretroviral (ARV) treatment, said Kim. Over 4 million people are in need of life-prolonging drugs in Africa, but less than 5 percent are receiving it in a continent further handicapped by grinding poverty, weak public health systems and, in some cases, limited political commitment. "Treatment scaleup has been theoretical - people have been paying lip service to it, but are not into it. The focus of efforts has been funding and price cuts, but that's all press releases [rather than action]," said Kim. "We are trying to change the nature of the discourse." To get on target for 3 by 5, new approaches are needed to provide access quickly and cheaply for far larger numbers of people. "They need to be community-based; [delivered by] community health workers [providing] fixed-dose combinations [as opposed to several brand-name pills a day]; and having doctors deal mainly with complications ... It's not the way I would do it in the United States, but there is clear evidence that it can work," Kim said. The alternative, an orthodox approach that focuses on viral loads and treatment support, requires a relatively elaborate infrastructure that most African cities, let alone the rural areas, do not possess. It would mean "few patients treated and a lot of people dead". Although funding levels for prevention, treatment and care programmes continue to lag behind needs, the focus for AIDS activists has begun to shift to how external finances are delivered and used. "We have managed to mobilise significantly more resources; the real question is how do we spend the money and make the money work," Paul Seitz, president of the Washington-based Global AIDS Alliance told PlusNews. "The key things are to support local groups in action planning, giving them skills to design their own ARV programmes, helping them with treatment literacy, and making it culturally acceptable," he said. A central principal of 3 by 5 is that people living with AIDS should play key roles in providing universal access to ARVs, assisting in the development of programmes, and helping to fight discrimination by their involvement as paid staff or volunteers for service providers. The medical humanitarian agency, Medecins Sans Frontieres (MSF), has pioneered the provision of ARVs in "resource poor" communities and, said Kim, would serve as a model for a stripped down treatment programme that could be replicated on a wider scale. The simplification of treatment, including use of three-in-one fixed-dose combinations (FDCs] of ARVs, has allowed MSF to scale up its AIDS treatment programmes from 1,500 patients in 10 countries to 13,000 patients in 25 countries in two years, MSF said in a press release this week. "Using FDCs, eliminating the requirement of CD4 [an indication of the strength of the immune system] and viral load tests to begin treatment, and delegating responsibility from doctors to nurses and clinical officers have been essential to MSF's rapid expansion of the number of patients benefiting from treatment," the agency explained. Successful pioneering ARV programmes have shown that "community health workers can take on significant responsibilities in counselling, psychosocial support to patients and their families, adherence support, nutritional support, home care and palliative care, and monitoring patients for toxicity and clinical failure," UNAIDS said in its 2004 global report on the epidemic released last week. However, the challenges of scaling up are inherent in WHO's interim target of three million people on ARVs - just half of the total number of people that currently need treatment. A comprehensive AIDS response would mean that drugs for opportunistic infections would also be available. But in Africa, WHO estimates that only 30 percent of HIV-infected people with TB - a common and deadly opportunistic infection - have access to TB medication. A related concern has been the potential for the marginalisation of people - based on gender, class, region or sexuality - to access life-saving treatment. "Until resources and programmes are available for all people who need them, ensuring equity of access to services - fair distribution of treatment - will be a key challenge for governments and health care providers," the UNAIDS report noted.