AFRO-NETS> Kaiser Daily HIV/AIDS Report-Mon, 6 Aug 2001

[Cecilia Snyder <csnyder@ccmc.org>]

Kaiser Daily HIV/AIDS Report-Mon, 6 Aug 2001
--------------------------------------------

* Researchers Endorse HAART Regimen Adapted for Developing Nations,
   Rural Settings
* Combining Antiretroviral Programs with National Tuberculosis
   Programs in Africa May Prevent Antiretroviral 'Anarchy'

OPINION


Researchers Endorse HAART Regimen Adapted for Developing Nations, Ru-
ral Settings

A pilot project that administered directly observed therapy with
highly active antiretroviral therapy (DOT-HAART) to people living in
a "poor community in ru- ral Haiti" produced positive results, demon-
strating that drug therapy can be successfully implemented in low-
income areas and developing nations, according to new research pub-
lished in the Aug. 4 issue of the Lancet. In the 60-person study, Dr.
Paul Farmer and colleagues implemented in rural Haiti a DOT-HAART
program modelled after "successful tuberculosis-control efforts." The
program paired each HIV-positive participant with a "companion" --
often a community health worker -- who observed the patient's medi-
cine intake. The companion also responded to patient and family con-
cerns and offered "moral support." "Social support," such as assis-
tance with children's school fees, was also given to study partici-
pants, and patients met once a month to discuss "their illness and
other concerns." The researchers report that response to the DOT-
HAART regimen was "dramatic" and that side effects were "rare and
readily managed by community health workers and clinic staff." The
study also shows that the HIV- positive people who received HAART
were "far less likely" to require hospitalization than patients with
"untreated" HIV.

Combining Antiretroviral Programs with National Tuberculosis Programs
in Africa May Prevent Antiretroviral 'Anarchy'

Access to antiretroviral medications in Africa "could be an important
component of a strategy to support people living with HIV and AIDS,"
but without provision in a structured framework, the introduction of
such drugs could result in regional "chaos" and "anarchy," Anthony
Harries and colleagues of the National Tuberculosis Control Program
in Lilongwe, Malawi, write in a Lancet opinion piece. Africa is the
"epicenter" of the AIDS pandemic, but "ironically [it] is the region
least able to offer any challenge or opposition to the devastation
caused by the virus." In addition to the inaccessibility to needed
AIDS drugs, the "health infrastructure is incapable of monitoring vi-
ral load, immune status, or side effects of the drugs. Drug procure-
ment and distribution systems are weak, and drug interruptions are
likely. Theft of drugs from health institutions for sale in markets,
shops, private clinics and across national borders is a real concern.
There are no monitoring systems in place to check on drug adherence
or drug effectiveness." However, the authors write, "We believe that
it is feasible to put such a system in place in the public health
sector based on the successful model adopted for tuberculosis control
... to initiate a combined tuberculosis and antiretroviral drug pro-
gram." A system to deliver antiretrovirals would be based on the
"successful" directly observed treatment, short course (DOTS) model
used to deliver TB medicines. The goals of an antiretroviral program
would be to reduce mortality, morbidity and HIV transmission; treat
symptomatic HIV patients with "standardized, combination antiretrovi-
ral therapy"; and achieve 90% or higher treatment adherence rates for
the life of the patient. The authors note that the last goal is the
"highest priority," as high adherence rates reduce the risk of the
development of drug-resistant HIV strains.

  Successful Program Elements

  Based on the DOTS program, the authors recommend five "key elements"
for an antiretroviral delivery program:

*Government commitment: Nationwide coverage is the goal of the pro-
gram, with technical leadership stemming from a central antiretrovi-
ral unit integrated with the national tuberculosis control program.

*Case detection through passive case finding: The program should fo-
cus on moving symptomatic HIV-seropositive patients through voluntary
counselling and testing and into therapy. Offering drugs to asympto-
matic HIV-positive individuals is not feasible in countries with few
resources, and early treatment increases the risk of "cumulative side
effects, poor adherence and the development of multidrug resistance."

*Standardized antiretroviral regimens: The drug combinations must be
simple and bear the least number of side effects. Protease inhibitors
are "best avoided" due to their interactions with tuberculosis medi-
cines. A DOT program for the drug regimens must be "flexible," as
there currently is no once-daily treatment for HIV infection.

*Establishment of a regular drug supply: The "regular and uninter-
rupted procurement, distribution and safe storage of antiretroviral
drugs" is needed for the program.

*Establishment and maintenance of a monitoring system: Within each
program, an antiretroviral register should be established to record
individual patient information, with regular reporting on a quarterly
basis.

Integrating Programs

Harries and colleagues write, "We believe than an integrated tubercu-
losis and antiretroviral drug program is the best way forward." Such
a joint program would be "more cost-effective to build on the infra-
structure already on the ground for tuberculosis control," as these
programs already have the experience of providing, monitoring, and
supervising care over time and can contribute to the effective and
safe administration of antiretrovirals. In addition, as HIV is the
"main driving force" behind the current TB epidemic in Africa, a
joint program could best alleviate the TB "burden" on the continent.
And as TB is the "main opportunistic infection" from HIV, many pa-
tients will be common to both programs. The writers provide a series
of recommendations for a joint initiative:

*Use a central unit responsible for the operational running of all
program aspects;

*Regularly monitor for antiretroviral drug resistance;

*Prepare a joint program manual;

*Establish a recording and reporting system;

*Design a plan of supervision;

*Provide a team of counselors for disease counseling and support;

*Establish voluntary HIV counseling and testing;

*Secure a regular supply of antiretroviral drugs;

*Prepare a development plan for program funding.

The authors estimate that the cost of "the most basic HIV prevention
and care package in Africa" would be $3 billion annually, with the
additional provision of antiretrovirals increasing costs to $7.5 bil-
lion. However, such a program "would introduce the most advanced
level of care for people with HIV and AIDS who in most countries are
not receiving even the minimum standard." The writers conclude, "We
believe that a structured system of antiretroviral provision is ur-
gently needed in sub-Saharan Africa. If this is combined with an es-
sential package of care, the lot of patients living with AIDS could
improve and drug resistance be curtailed" (Harries et al., Lancet,
8/4).
The Kaiser Daily HIV/AIDS Report is published for kaisernetwork.org,
a free service of The Henry J. Kaiser Family Foundation, by National
Journal Group Inc. c 2001 by National Journal Group Inc. and Kaiser
Family Foundation. All rights reserved
Contact Daily Reports Staff Editorial
Tel: +1-202-672-5952
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mailto:dailyreports@kaisernetwork.org


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