Analysis and Comment

HIV and global health

Monitoring HIV treatment in developing countries

BMJ 2006; 332 doi: 10.1136/bmj.332.7541.602 (Published 9 March 2006)
Cite this as: BMJ 2006;332:602

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  1. Serena P Koenig, physician (skoenig@partners.org)1,
  2. Daniel R Kuritzkes, director2,
  3. Martin S Hirsch, professor of medicine3,
  4. Fernet Léandre, director4,
  5. Joia S Mukherjee, medical director5,
  6. Paul E Farmer, Presley professor of medical anthropology6,
  7. Carlos del Rio, director7
  1. 1 Division of Social Medicine and Health Inequalities, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA 02120, USA
  2. 2 Section of Retroviral Therapeutics, Brigham and Women's Hospital
  3. 3 Division of Infectious Disease, Massachusetts General Hospital, Boston
  4. 4 Partners In Health, Boston
  5. 5 Program in Infectious Disease and Social Change, Department of Social Medicine, Harvard Medical School, Boston
  6. 6 HIV and Tuberculosis Programmes, Zanmi Lasante, Cange, Haiti
  7. 7 Clinical Sciences and International Research, Center for AIDS Research, Emory University, Atlanta, GA, USA
  1. Correspondence to: S P Koenig
  • Accepted 1 December 2005

Laboratory monitoring of antiretroviral therapy helps limit resistance but is currently not feasible in developing countries. Alternative short term approaches are needed

HIV and AIDS remain the world's leading infectious cause of adult death despite the development of antiretroviral therapy. Although antiretroviral drugs have decreased HIV related mortality by about 80% in the industrialised nations,1 2 most people (92%) who need the drugs in non-industrialised nations do not have access to them.3 This is not surprising, as the international response to the epidemic has been inadequate in terms of both prevention and care. Yet there is some cause for optimism. Unprecedented multilateral and bilateral initiatives are poised to make comprehensive HIV care the world's best funded public health initiative. To maximise the effect of these resources, however, it is critical that HIV programmes adopt a comprehensive approach.

Need for simplified short term strategies

Human resources and healthcare infrastructures are severely limited in many of the countries that bear the greatest burden of HIV disease. We need to strike a balance between building systems for delivering antiretroviral drugs and investing in laboratory infrastructures to monitor treatment outcomes. In the short term, widespread implementation of antiretroviral drug programmes will be threatened if governments and providers in resource poor settings are required to follow the monitoring protocols currently used in middle and high income countries, which are costly and require vast human resources. After years of inadequate funding, the health systems in most developing countries have poorly functioning medical facilities, unreliable drug procurement systems, and a limited supply of essential medicines. In addition, most countries face a crisis in human resources, with insufficient numbers of healthcare providers, a problem that has been exacerbated by the high rate of HIV infection among doctors and nurses.

Even relatively simple procedures widely used to monitor drug safety (such as routine …

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