Scaling up antiretroviral treatment in resource-poor settings

Abstract

Anthony Harries and colleagues provide a valuable contribution to the debate on strategies for scaling up antiretroviral therapy.1Harries AD Schouten EJ Libamba E Scaling up antiretroviral treatment in resource-poor settings.Lancet. 2006; 367: 1870-1872Summary Full Text Full Text PDF PubMed Scopus (107) Google Scholar However, we feel that they overlook a critical lesson from the history of HIV/AIDS treatment in the developing world: cost and complexity of treatment are barriers that can, and must, be challenged.The paper points to major threats to sustainable antiretroviral roll-out: insufficient funding and staff, patient overload, high-cost medicines, and complexity of laboratory monitoring. Although these threats are real, it is worth noting that these same threats were cited as arguments against scale-up of first-line therapy.2Marseille E Hofmann P Kahn J HIV prevention before HAART in sub-Saharan Africa.Lancet. 2002; 359: 1851-1856Summary Full Text Full Text PDF PubMed Scopus (181) Google ScholarIf second-line drugs are too expensive, costs must be lowered. If pill burden threatens good adherence, fixed-dose combinations and better second-line drugs must be developed. We must advocate for tools better adapted to field realities, for better staff salaries, and further empowerment of nurses, clinical officers, affected individuals, and communities. These are not utopian ideals. According to WHO, Chinese generic antiretrovirals could render second-line treatment as affordable as first-line;3Zarocostas J WHO official warns of crisis in supply of low cost AIDS drugs.BMJ. 2005; 311: 1104Crossref Scopus (1) Google Scholar further fixed-dose combinations are in development, and simplified methods of measuring CD4 count4Mwaba P Cassol S Nunn A et al.Whole blood versus plasma spots for measurement of HIV-1 viral load in HIV-infected African patients.Lancet. 2003; 362: 2067-2068Summary Full Text Full Text PDF PubMed Scopus (61) Google Scholar and viral load5Sample I Scientists who put lives before profits.Guardian. Jan 13, 2006; Google Scholar are becoming available.We wholeheartedly endorse the call for simplicity to maximise access to essential health care in the face of limited resources. First-line rollout is the priority, but barriers that exclude access to second-line drugs must not be taken for granted. Affordable, two-pills-a-day triple therapy is only available thanks to strong political advocacy and a refusal to accept that antiretroviral therapy was unattainable. The same logic, however idealistic it might currently seem, must be applied to ensure that patients for whom first-line treatment fails are not denied a second chance.We declare that we have no conflict of interest. Anthony Harries and colleagues provide a valuable contribution to the debate on strategies for scaling up antiretroviral therapy.1Harries AD Schouten EJ Libamba E Scaling up antiretroviral treatment in resource-poor settings.Lancet. 2006; 367: 1870-1872Summary Full Text Full Text PDF PubMed Scopus (107) Google Scholar However, we feel that they overlook a critical lesson from the history of HIV/AIDS treatment in the developing world: cost and complexity of treatment are barriers that can, and must, be challenged. The paper points to major threats to sustainable antiretroviral roll-out: insufficient funding and staff, patient overload, high-cost medicines, and complexity of laboratory monitoring. Although these threats are real, it is worth noting that these same threats were cited as arguments against scale-up of first-line therapy.2Marseille E Hofmann P Kahn J HIV prevention before HAART in sub-Saharan Africa.Lancet. 2002; 359: 1851-1856Summary Full Text Full Text PDF PubMed Scopus (181) Google Scholar If second-line drugs are too expensive, costs must be lowered. If pill burden threatens good adherence, fixed-dose combinations and better second-line drugs must be developed. We must advocate for tools better adapted to field realities, for better staff salaries, and further empowerment of nurses, clinical officers, affected individuals, and communities. These are not utopian ideals. According to WHO, Chinese generic antiretrovirals could render second-line treatment as affordable as first-line;3Zarocostas J WHO official warns of crisis in supply of low cost AIDS drugs.BMJ. 2005; 311: 1104Crossref Scopus (1) Google Scholar further fixed-dose combinations are in development, and simplified methods of measuring CD4 count4Mwaba P Cassol S Nunn A et al.Whole blood versus plasma spots for measurement of HIV-1 viral load in HIV-infected African patients.Lancet. 2003; 362: 2067-2068Summary Full Text Full Text PDF PubMed Scopus (61) Google Scholar and viral load5Sample I Scientists who put lives before profits.Guardian. Jan 13, 2006; Google Scholar are becoming available. We wholeheartedly endorse the call for simplicity to maximise access to essential health care in the face of limited resources. First-line rollout is the priority, but barriers that exclude access to second-line drugs must not be taken for granted. Affordable, two-pills-a-day triple therapy is only available thanks to strong political advocacy and a refusal to accept that antiretroviral therapy was unattainable. The same logic, however idealistic it might currently seem, must be applied to ensure that patients for whom first-line treatment fails are not denied a second chance. We declare that we have no conflict of interest.