Elsevier

The Lancet

Volume 358, Issue 9279, 4 August 2001, Pages 410-414
The Lancet

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Preventing antiretroviral anarchy in sub-Saharan Africa

https://doi.org/10.1016/S0140-6736(01)05551-9Get rights and content

Summary

Combination antiretroviral therapy has dramatically improved the survival of patients living with HIV and AIDS in industrialised countries of the world. Despite this enormous benefit, there are some major problems and obstacles to be overcome.1 Treatment of HIV-infection is likely to be lifelong.2 Unfortunately, many HIV-infected individuals cannot tolerate the toxic effects of the drugs, or have difficulty complying with treatment which involves large numbers of pills and complicated dosing schedules. Poor adherence to treatment leads to the emergence of drug-resistant viral strains that need new combinations of drugs or new drugs altogether.

Section snippets

Use of antiretroviral therapy in sub-Saharan Africa

About 70% of the estimated 36·1 million people in the world with HIV and AIDS live in sub-Saharan Africa, and 84% of all the estimated deaths due to HIV and AIDS since the start of the pandemic have occurred in this region.3 Africa is the epicentre of this pandemic, yet ironically is the region least able to offer any challenge or opposition to the devastation caused by the virus. With a few exceptions, strategies to prevent the spread of HIV have been unsuccessful. Good quality HIV counselling

Dangers of antiretroviral therapy in sub-Saharan Africa

Widespread, unregulated access to antiretroviral drugs in sub-Saharan Africa could lead to the rapid emergence of resistant viral strains, spelling doom for the individual, curtailing future treatment options, and leading to transmission of resistant virus. There are few physicians skilled in the use of antiretroviral drugs. The health infrastructure is incapable of monitoring viral load, immune status, or side-effects of the drugs. Drug procurement and distribution systems are weak, and drug

National tuberculosis control programmes

The overall objective of tuberculosis control is to reduce mortality, morbidity, and transmission of the disease until it no longer poses a threat to public health. The strategy is simple. Standardised combination chemotherapy is provided to, at least, all sputum smear-positive tuberculosis patients. This treatment cures the disease and prevents future transmission of infection within the community. Targets for tuberculosis control include curing 85% of detected new smear-positive tuberculosis

Framework for an antiretroviral programme in sub-Saharan Africa

The overall objective of an antiretroviral programme would be to reduce mortality, morbidity, and transmission of HIV. The strategy would be to use standardised, combination antiretroviral therapy for HIV seropositive patients with symptoms. The targets for antiretroviral therapy would be lifelong treatment once the patient has started on therapy and drug adherence rates of 90% or greater. Achievement of excellent adherence rates is the highest priority because this is the best way of reducing

Why have a joint programme?

In most of sub-Saharan Africa there have been repeated requests for tuberculosis control and AIDS control programmes to work together. A joint tuberculosis and antiretroviral initiative could provide a real focus for collaboration. An independent and parallel antiretroviral treatment and delivery system could be implemented, but we believe that such a step would be counter-productive.

It would be more cost-effective to build on the infrastructure already on the ground for tuberculosis control.

Key operations of a joint programme

We believe that an integrated tuberculosis and antiretroviral drug programme is the best way forward. Various key operations need to be established and sustained:

A central unit should be established that has an overall programme manager, with two deputy managers (one in charge of a national tuberculosis programme and one in charge of antiretroviral therapy) reporting to the programme manager. The central unit is responsible for the operational running of all aspects of the programme. Regional

Conclusion

We believe that such a structure may enable antiretroviral drugs to be used effectively and safely within sub-Saharan African countries. Having this framework in place, integrated with a tuberculosis control programme, might appeal to donors who otherwise might be reluctant to embark on support for such care. The details of how the structure is implemented need to be worked out, and will no doubt vary from country to country.

However, there is an important caveat to this viewpoint. Many

References (19)

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