Elsevier

The Lancet

Volume 368, Issue 9534, 5–11 August 2006, Pages 505-510
The Lancet

Public Health
The WHO public-health approach to antiretroviral treatment against HIV in resource-limited settings

https://doi.org/10.1016/S0140-6736(06)69158-7Get rights and content

Summary

WHO has proposed a public-health approach to antiretroviral therapy (ART) to enable scaling-up access to treatment for HIV-positive people in developing countries, recognising that the western model of specialist physician management and advanced laboratory monitoring is not feasible in resource-poor settings. In this approach, standardised simplified treatment protocols and decentralised service delivery enable treatment to be delivered to large numbers of HIV-positive adults and children through the public and private sector. Simplified tools and approaches to clinical decision-making, centred on the “four Ss”—when to: start drug treatment; substitute for toxicity; switch after treatment failure; and stop—enable lower level health-care workers to deliver care. Simple limited formularies have driven large-scale production of fixed-dose combinations for first-line treatment for adults and lowered prices, but to ensure access to ART in the poorest countries, the care and drugs should be given free at point of service delivery. Population-based surveillance for acquired and transmitted resistance is needed to address concerns that switching regimens on the basis of clinical criteria for failure alone could lead to widespread emergence of drug-resistant virus strains. The integrated management of adult or childhood illness (IMAI/IMCI) facilitates decentralised implementation that is integrated within existing health systems. Simplified operational guidelines, tools, and training materials enable clinical teams in primary-care and second-level facilities to deliver HIV prevention, HIV care, and ART, and to use a standardised patient-tracking system.

Section snippets

Background

Around 40 million people worldwide are thought to be infected with HIV. Many of these people live in developing countries. Since 2001, the WHO has been promoting a public-health approach to antiretroviral therapy (ART) to improve access in resource-poor settings. Existing guidelines for ART,1, 2 and the prevention of mother-to-child transmission3 were revised earlier this year, and separate guidelines for treating children were developed.4, 5, 6 Other publications support the public-health

Why a public-health approach?

Extensive evidence shows that combined antiretrovirals can substantially extend the life of those with HIV/AIDS. Guidelines for industrialised countries cover individual patient management delivered by specialist doctors prescribing from the full range of antiretrovirals, supported by routine high-technology laboratory monitoring.18, 19 Such an approach is not feasible in resource-limited settings where doctors are scarce (eg, one per 12 500 population in Uganda20), laboratory infrastructure is

Standardised regimens and simplified formularies

The first, arguably most important, achievement has been to standardise first-line and second-line treatments. There are three classes of oral antiretrovirals available: nucleoside and non-nucleoside reverse transcriptase inhibitors (NRTI and NNRTI) and protease inhibitors (PI). Public-health therapy readily accommodates the use of two sequential triple-drug ART regimens. On the basis of available data, the initial consensus was to use one NNRTI in first-line treatment, supported by an NRTI;2

Decentralised, integrated delivery of care

Population-wide implementation needs simplified and standardised operational approaches. In tandem with the normative work, the WHO has developed and adapted the IMAI/IMCI approach to put into action ART guidelines and evidence-based standards, and provide implementation tools to support decentralisation of ART within integrated HIV services.12 Increasingly with treatment scale-up, most ART is delivered outside specialist tertiary centres, decentralised to the health district.17

IMAI/IMCI

Evidence for the public-health approach to ART provision

The WHO's public-health approach to providing ART is still being refined. Gaps in knowledge have limited the standardisation of some treatment approaches; others have not yet been adequately assessed. The WHO is to convene an expert meeting to review the evidence and prioritise a research agenda relevant to the public-health approach to ART. Several fundamental questions are already apparent (panel)

Conclusions

The public-health approach promoted by WHO underpins the successful experiences of several countries in scaling up HIV/AIDS services and is based on the principles of simplification, standardisation, decentralisation, equity, and patient and community participation, and has been pivotal in unlocking the treatment agenda, and starting to close the treatment gap between rich and poor countries. More than a million people in developing countries are benefiting from simplified and standardised

References (30)

  • L Ferradini et al.

    Scaling up of highly active antiretroviral therapy in a rural district of Malawi: an effectiveness assessment

    Lancet

    (2006)
  • C Mundy et al.

    Evaluation of microscope condition in Malawi

    Trans R Soc Trop Med Hyg

    (2000)
  • R Beaglehole et al.

    Public health in the new era: improving health through collective action

    Lancet

    (2004)
  • Scaling up anti-retroviral therapy in resource-limited settings: guidelines for a public health approach

    (2002)
  • Scaling up antiretroviral therapy in resource-limited settings: treatment guidelines for a public health approach (2003 revision)

    (2004)
  • Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: guidelines on care, treatment and support for women living with HIV/AIDS and their children in resource-constrained settings

    (2004)
  • Antiretroviral therapy of HIV infection in infants and children in resource-limited settings, towards universal access: recommendations for a public health approach

    (2006)
  • Antiretroviral therapy of HIV infection in adults and adolescents in resource-limited settings: recommendations for a public health approach (2006 revision)

    (2006)
  • Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: recommendations for a public health approach (2006 revision)

    (2006)
  • Guidelines for co-trimoxazole prophylaxis for HIV-related infections in children, adolescents and adults in resource-limited settings: recommendations for a public health approach

    (2006)
  • Revised WHO clinical staging and immunological classification of HIV/AIDS and case definitions of HIV and related conditions

    (2006)
  • Recommendations on the diagnosis of HIV infection in infants and children: a public health approach

    (2006)
  • Guidance on ethics and equitable access to HIV treatment and care

    (2004)
  • The practice of charging user fees at the point of service delivery for HIV/AIDS treatment and care

    (2005)
  • IMAI/IMCI (toolkit can be accessed by clicking on Sharepoint Registration at bottom of page)

  • Cited by (0)

    View full text