Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Naivette dictates policies
- Abhishek Puri (28 November 2004)
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WHO’s 3 by 5 initiative: An unrealistic fashion statement
- Udaya S Mishra (29 November 2004)
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Building on hope and good practice
- Dr Mandeep Dhaliwal, Carolyn Green, Ade Fakoya, Susie Mclean, Pam Decho (2 December 2004)
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Adjustments by donors & community organizations
- Kelvin G Billinghurst (16 December 2004)
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Abhishek Puri, Dr. Patiala,Punjab 147001
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Over the period of time,a subtle shift has taken place from prevention strategies to "curing".No doubt,HAART has revolutionised the HIV treatment;However,introducing it on a large scale has potential problems. 1)Majoirty of the newly diagnosed HIV patients have Multi Drug Resistant strains.Checking each patient would significantly increase the costs;goes against logic to reduce the healthcare burden. 2)The side effects of the therapies remain substantial.In developing countries,monitoring the treatment would again require substantial investment,since the drug therapy needs to be directed mainly by CD4 counts and the viral loads by PCR techniques. 3)AIDS is a whole constellation of symptoms.The cost of the treatment for oppurtunistic infections has not been factored in. 4)In case of DOT,as mentioned by the authors,significant problems still remain as to the follow up.This problem is acute in the rural areas in India where I have worked.Tuberculosis hasnt merited enough attention in the health care budgets of the State Governments since primarily the programme remains funded by the Centre.There is apathy on the part of the patient and the healthcare worker at the grassroots level.The idea of DOTS ironically is its cause of failure too.In the absence of proper audit many patients fail to turn up for follow up.Misreporting or under reporting is one big factor.Part of the reason is the extensive paperwork.The other reason is the lack of motivation and proper remuneration.In AIDS infected patients,the problem is bound to be more acute.Contrast with the high profile campaign of Polio immunisation.Its the regular advertisements and effective use of mass media that has brought down the incidence of Poliomyelitis effectively. The decision of the Indian government to introduce the free antiretroviral drugs in areas of high prevalence,has consistently shown low life indicators.This coupled with poverty and ignorance would not help to achieve the targets.The problem of targetted healthcare,by means of primary health care is out of scope for discussion here. The source of drugs needs to be defined.The generic manufacturers in India need to ensure stringent quality for the drugs.Unfortunately it is not always adhered to.In the recent case one "reputed" manufacturer had to recall the entire batch of drugs for failing the bioequivalence studies. There is another substantial risk of people suffering with HIV indulging in high risk sexual behaviour.Many people are given to this belief that viral loads being "zero"(as indicated by PCR) means that they are no longer affected.This would negate the entire effort of the 3 by 5 programme anyway. I feel strongly,that prevention is better than cure.Since the traditional methods of communication have failed,it calls for a relook at the prevention strategies.This has shown to be far more effective in changing the attitudes of sexual practices including high risk ones.Being faithful to a single partner needs to be conveyed effectively. This could probably the answer for the stemming the increasing numbers of people being infected with the virus. Competing interests: None declared |
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Udaya S Mishra, Takemi Fellow, department of Population and International Health Harvard school of Public Health, 665, Huntington Avenue, Boston, MA 02115, USA
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While access to antiretrovirals has been a common barrier in AIDS care, this lack of access has different aetiology in different populations. The primary handicap lies in identifying AIDS victims and accordingly making the necessary provision of drugs, even then it remains debatable as to whether ensuring access to ARV drugs would help control the spread of AIDS. While stigma associated with HIV limits identification, at the same time it limits access to treatment too, if anonymity and confidentiality regarding the HIV status of the patient is not maintained by treatment providers. The other issue of adherence to treatment is perhaps related to treatment provision as well as the support system in place to ensure intake of drugs. The unresolved debate between the stress on prevention and treatment argues in favour of putting more and more of AIDS victims under treatment which will arrest its spread as being under treatment reduces the risk of transmission. The awareness and prevention efforts are by no means a second priority as they will help largely against stigma and treatment of HIV will receive a positive response from household and the community. While identification of the infected is at stake, provision does not ensure treatment coverage and thereby optimism of putting the infected under treatment fails. Precise identification of the infected along with the prospective infections in terms of vulnerable groups needs to be adjudged for any successful implementation of any treatment programme. In a pragmatic sense, attaining control over vulnerability to HIV provides greater optimism towards containing the spread of HIV. Competing interests: None declared |
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Dr Mandeep Dhaliwal, Head: Care & Impact Mitigation International HIV/AIDS Alliance, 104-106 Queens Road, Queensberry House, Brighton, BN3 1XF, Carolyn Green, Ade Fakoya, Susie Mclean, Pam Decho
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While WHO's 3x5 initiative can be considered ambitious, it is an inspirational target that has served to galvanise and mobilse the global community around ARV treatment. The political, moral and public health benefits of WHO's 3x5 initiative should not be underestimated. WHO's 3x5 initiative has engendered hope. Additionally, much good practice in delivering ARV treatment in resource-poor settings has been establsihed. The International HIV/AIDS Alliance (Alliance) supports community action on AIDS in over 25 developing countries. As a partner in WHO's 3x5 initiative, the Alliance is involved in efforts to scale up treatment in many of these developing countries. In countries such as the Ukraine, Cambodia, Burkina Faso and Zambia where the Alliance and its NGO partners are working closely with public health facilities to scale up treatment, ARV treatment programmes are seen as a way of strengthening health systems or broader models of care. In addition, communities and NGOs are seen as an essential partners in safe and effective scale up of ARV treatment services. Physicians and other health care workers working developng countries such as Ukraine, Cambodia, Burkina Faso and Zambia are acutely aware of the importance of communities in treatment programmes. The role of people with HIV, particularly those already receiving ARV treatment, is especially important in the area of treatment support, which includes adherence and prevention. In the Alliace's experience, building treatment friendly communties is the key to extending coverage and sustaining the quality of ARV treatment. The specific advantages of engageing communities for ARV treatment are in the following areas: -treatment support including treatment literacy, adherence support, counselling, food support, prevention -community education on ARV treatment and prevention -planning, implementing and monitoring of ARV treatment programmes, including defining patient selecion criteria In fact, where community organisations are actually providing ARV treatment, for example in Burkina Faso, the clinical results have been good. The challenge here is extending the services to treat more people. The Alliance and its NGO partners' close involvement in the government ARV treatment programmes in the Ukraine and Zambia stand as testimony to the fact that community engagement with public health scale up of ARV treatment is both possible and contributes to an ever-growing body of evidence and examples good practice. These must now be learned from and extended. Competing interests: None declared |
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Kelvin G Billinghurst, Training Officer & Consultant Project Support Group Southern Africa, South Africa, 1200. Tel 27-11-9171603 Fax: 27-11-9171605
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While the nature and type of health care services varies widely across the developing world, health care delivered through community based organizations and structures have the capacity to expand and augment such services. The issues raised by Furber et al (continuum of care, stigma, health systems and access) concerning the WHO 3 by 5 ARV expansions can be addressed through effective community based home care programmes. This is necessary in the context of HIV and key to move health services from an “acute” to “chronic” model of care for HIV AIDS clients. The introduction of ARV’s and better management of Opportunistic Infections in developing countries will markedly increase the workload of health care workers already experiencing acute staff shortages, overloaded hospital wards and limitations to existing health resources. HIV among health workers will further accentuate these short comings. Currently within many health services of the developing world, HIV clients are readily discharged into a vacuum where ongoing care is uncertain. Communities, in response, raise the threshold for further health consultations because of this neglect, lack of drugs and mismanagement.
By home care programme one is not talking about random community members visiting clients on an ad hoc basis with little training and organization. But an organized recruitment of community volunteers who deliver a core package of services to the sick and dying integrated with orphan care, supported by regular training and debriefing meetings and an effective management and monitoring structure. These can be at a cost that permits the scaling up to many communities in many countries. Are such programmes too ambitious or unrealistic? Numerous HIV AIDS conferences have presented many such programmes in recent years. Cost effective, community driven and culturally sensitive these programmes can and have demonstrated the ability to be scaled up for wider geographical coverage. However, if community based organizations are to significantly contribute to the expansion of an ARV programme adjustments will be required at a number of levels. The first is the recognition by countries and donors of the contribution that community based organizations can make and willingness to partner with such structures. In some countries and areas vague policies have created greater confusion and points of conflict between government health services and community structures or Non Government Organizations (NGO’s). Successful organizations are often met with suspicion and distrust by government personnel. Some organizations such as the Global Fund for HIV AIDS Malaria and Tuberculosis, World Bank Multi Country AIDS Programme (MAP) and other developmental agencies have encouraged close associations with community structures and specified funding through their programmes. There is a need for donors to support intermediate or middle management type organizations that have the time, energy, willingness and support to strengthen grass root community based organizations (CBO’s) or NGO’s. Many community home care organizations have sprung up in response to potential funding (mushroom or briefcase organizations). This is understandable considering the poverty affecting many of these communities. They promise much, deliver little and often overshadow organizations effectively delivering services. Donors in response then favour well known, larger national organizations, bypassing community based programmes for funding and keeping control “in house”. It will be easier for donors to support multiple “middle management organizations” than to supervise the 100 000 trained health providers and treatment supporters for implementing the WHO 3 by 5. The type of support intermediate structures could provide includes finances and on the ground selection process, monitoring skills, management, technical assistance and ongoing training. Additional management burdens are often placed by donors on recipient organizations who reside in areas where capacity and skills are often lacking and the recruitment of skilled staff is difficult. Donors frequently restrict the areas of funding to selected areas. Some donors will fund support for community members and not capital project, others fund orphan support, while resisting support for sick and dying adults and few seem willing to support project staff with salaries, wages or administration support. Recipient organizations offering comprehensive services therefore need to submit multiple funding proposals to donors. While having multiple donors is healthy and avoids excessive dependency it does require significant time, work & energy in preparing & submitting proposals. Monitoring and evaluation has increased in prominence in recent years and while having an essential management role, it can also increase the workload on recipient organizations. It is not unusual for organizations to report back on using numbers of different systems indicators and timeframes. The simplification of these processes would increase the number of organizations who could participate in scaling up the coverage and scope of an ARV programme. While donor organizations need to make adjustments to support the WHO 3 by 5 programme, so also do community organizations and home care programmes. These include –
The partnership between donors and community based home care programmes both making adjustments should accelerate the quality and accessibility to ARV’s. Competing interests: None declared |
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