ViewpointCommunity-based approaches to HIV treatment in resource-poor settings
Section snippets
Why AIDS prevention alone is insufficient
The dimensions of the global HIV crisis are such that predictions termed alarmist a decade ago are now revealed as sober projections.1 In 2000, HIV overtook tuberculosis as the world's leading infectious cause of adult deaths. HIV has, in fact, overtaken the 1918 influenza epidemic as the most devastating communicable cause of adult death since the bubonic plague of the 14th century.2 The social impact of HIV has been particularly severe in Africa, where an estimated 14 million children have
One community's experience: the HIV Equity Initiative
Haiti is by all conventional criteria the poorest country in the western hemisphere and one of the poorest in the world:13 per capita gross national product (GNP) is around US$400; unemployment exceeds 70%; and fewer than one in 50 Haitians have regular employment.14 Not coincidentally, Haiti is also the hemisphere's most HIV-burdened country.15 In 1999, UNAIDS reported national HIV seroprevalence as 5% among women attending antenatal clinics—and rates were twice as high in urban slums.11 The
Expanding the HIV Equity Initiative
We believe that if DOT-HAART can be implemented in the devastated Central Plateau of Haiti it can be implemented anywhere. Our experience further suggests that HIV therapy can reinvigorate flagging prevention efforts. Although AIDS remains a stigmatised disease in Haiti, we believe that access to effective therapy has lessened AIDS related-stigma. The demand for HIV testing, and the opportunity for counselling, has risen since HAART was made available.
During the next 3 years, we hope to expand
Objections to HAART in resource-poor settings
The two primary objections to use of HAART in poor communities have been the high costs of the medications and the lack of infrastructure necessary to deliver them effectively. The debate regarding pricing of antiretrovirals has been reviewed elsewhere.28, 29 As noted, there is little science to drug pricing. Several firms, including one based in India, have developed very low-cost formulations of zidovudine, 3TC, D4T, ddI, and nevirapine. The monthly retail cost of three drugs is already as
Rethinking costs and benefits
We believe that much of the policy debate regarding the role of HAART in responding to AIDS has been misguided. The belief that treatment may be reserved for those in wealthy countries whereas prevention is the lot of the poor might be less repugnant if we had highly effective preventive measures. We do not. We have argued that we need better preventives, including vaccines, and also a campaign to make HAART available to those who need it most. Where HIV is the leading cause of adult death, a
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