Education And Debate

Antiretroviral treatment in developing countries: the peril of neglecting private providers

BMJ 2003; 326 doi: http://dx.doi.org/10.1136/bmj.326.7403.1382 (Published 19 June 2003) Cite this as: BMJ 2003;326:1382
  1. Ruairí Brugha, senior lecturer in public health ([email protected])
  1. Health Policy Unit, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC1E 7HT
  • Accepted 17 March 2003

Increased access to antiretroviral drugs is vital to maintain developing countries with high rates of HIV infection. But unless treatment is properly controlled, these drugs could rapidly become useless

Only 5% of the 5.5 million people in developing countries who need antiretroviral treatment currently receive it.1 New initiatives and global partnerships are trying to increase access to antiretroviral drugs- for example, the International HIV Treatment Access Coalition,1 guidelines for scaling up antiretroviral treatment,2 and employee programmes under the umbrella of the Global Business Coalition on HIV/AIDS. However, these initiatives largely ignore the fact that most poor people who suspect they have a sexually transmitted infection seek care in the private sector because of the stigma attached.3 4 The main care providers for HIV disease in the poorest countries are therefore likely to be private medical practitioners, pharmacists, and traditional and informal providers, such as drug vendors, who are often unregulated and dispense drugs illegally.4 5 Improper use of antiretroviral drugs may result in development of resistant HIV, so it is important to take account of private providers and regulate their behaviour.

Sign from private clinic in Phnom Penh, Cambodia

Dangers of unregulated prescribing

Although recent reductions in the price of these drugs are welcome, the rapid increase in legal distribution will inevitably increase illegal leakage into the private sector. Evidence of uncontrolled use is already emerging in the formal and, more worryingly, informal private sector. A study from Zimbabwe in 2000 reported that a quarter of 68 private physicians were prescribing antiretroviral drugs and a quarter of 80 pharmacies were dispensing them to patients, although insurance companies did not reimburse for their use.6 The authors described prescribing practices as “therapeutic anarchy,” with prescribers and dispensers using “any ARV that they could …

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