[afro-nets] Challenges to Scaling up Antiretroviral Therapy

[Dr Rana Jawad Asghar <jawad@alumni.washington.edu>]

Challenges to Scaling up Antiretroviral Therapy
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by Mary Beth Nierengarten

Feb. 9, 2004 (San Francisco) - Decreasing anti-HIV drug prices,
design of simpler drug regimens, increasing funding, and improv-
ing political reception mean that the time is ripe for scaling
up antiretroviral (ARV) treatment in developing countries. But
stiff challenges remain as countries gear up to meet the goal of
the recent "3 by 5" initiative by the World Health Organization
(WHO) to expand ARV treatment to three million people infected
with HIV in developing countries by the end of 2005.

Immense levels of advocacy have been brought to bear on the AIDS
crisis, said David Miller, MD, WHO, in a press briefing here on
the opening day of the 11th Conference on Retroviruses and Op-
portunistic Infections, but "less than 2% of the population in
Africa has been tested for HIV, which means that we are left
with a real problem to scaling up access to ARV treatment."

Compounding the lack of HIV testing and counseling is the low
demand for ARV agents in countries where they are free. "Even
when ARVs are free," said Alex Coutinho, MD, executive director
of TASO in Uganda, "you don't have people breaking down doors to
get it." Since Uganda began scaling up ARV in 1996, however, it
has learned that the key to creating demand for ARVs is to get
people involved. "If you give ARV in total secrecy," emphasized
Dr. Coutinho, you will not have people coming forward."

The country now has 300 to 400 people receiving ARV who are ac-
tively sharing their experiences in the community. In 2003, of
the 100,000 people who required treatment, about 12,000 are now
receiving ARV, with about 95% adherence.

Continual focus on prevention is critical to scaling-up efforts.
According to Dr. Coutinho, the ABC prevention model (abstinence,
be faithful, or use condoms) used in Uganda has worked because
it has given people a menu of choices. He would change this
model to ABCD, he added; the "D" would stand for determining and
declaring HIV status.

But Ambassador Stephen Lewis, United Nations special envoy on
HIV/AIDS in Africa, suggested that the ABC model does not work
for an emerging group of people who are increasingly at high
risk of contracting HIV - married women in Africa. "Emerging
evidence from UNAIDS shows increasing infections are taking
place in what women see as monogamous relationships," he said.
The toll this could take on women in Africa is seen in a dire
statistic - according to Ambassador Lewis, two thirds of the 10
million Africans between the ages of 15 and 24 years are girls
and women.

Challenges in scaling up treatment in these women of child-
bearing age may be compounded by emerging data on the high
prevalence of resistance associated with single-dose nevirapine
used to prevent HIV transmission from mother to infant.

11th CROI: Abstracts 3, 4, 7. Presented Feb. 8, 2004.
Reviewed by Gary D. Vogin, MD

Mary Beth Nierengarten is a freelance writer for Medscape.