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