Stable drug supply and distribution in an integrated healthcare delivery system, but unconfirmed need for daily witnessed dosing

Abstract

We agree with Dr Harries that future large-scale antiretroviral treatment programmes in resource-poor settings would do well to emulate several aspects of the directly observed treatment short course (DOTS) strategy; specifically the consolidation of multilateral political support development of reliable diagnostic systems assured drug supply and infrastructure for comprehensive outcome assessment. We suggest caution however with respect to the role of daily witnessed dosing. Although this is only a single component of the DOTS strategy it has been promoted as a centrepiece of such programmes. Dr Harries acknowledges appropriate skepticism regarding the attributable impact of witnessed dosing on improving tuberculosis treatment outcomes. Others however have argued that witnessed dosing is an indispensable component of DOTS programmes. Witnessed dosing of HIV antiretroviral therapy is complicated by the need for lifelong treatment daily medication dosing and the consequent impact on individual rights in the setting of a highly stigmatizing disease. For these reasons we suggest that witnessed dosing is the most problematic element in the large-scale expansion of HIV treatment access in resource-poor settings based on the DOTS model. Otherwise we entirely agree with Dr Harries that HIV treatment programmes should be conceptualized as a broad package of support to the patient within the framework of a chronic care model similar to that of existing tuberculosis programmes. (excerpt)