Perspectives and Practice in Antiretroviral Treatment

Abstract

No one questions the gravity of the HIV/AIDS crisis that now faces sub-Saharan Africa, though many have raised questions about Africa’s ability to mount a meaningful response. Even the most casual glance at most of Africa’s health-care infra- structure, budgets and human resources would offer little confidence that the complex issues surrounding modern antiretroviral therapy can be managed effectively for such a large population of patients. Existing medical facilities are not prepared to support the care needs of large numbers of ambulatory patients, especially when the demands for training and research are superimposed. In the past, the high cost of antiretrovirals (ARVs) made treat- ment of impoverished HIV-infected patients beyond reach. HIV programmes understandably targeted prevention and palliative care strategies. However, the continuing decline in the cost of antiretroviral drugs combined with ethical concerns about pursuing prevention alone make it clear that treatment is coming to Africa. Nevertheless, if the promise of treatment is to be achieved, cost-effective systems of care must emerge that are capable of ensuring unparalleled levels of patient adherence. Poorly administered ARVs will have no effect on the course of HIV infection, and will only result in a reservoir of drug-resistant strains of HIV. Therefore, demon- strations of models of comprehensive HIV care that have proven effective in countries like Kenya are of the highest priority. The epidemiological facts of Kenya alone illustrate the con- flict between the burden of HIV/AIDS and the immediate need for a response: Kenya has an estimated 2.5 million people, about 15% of the adult population, with HIV, which ranks it the fourth most-affected country in the world (behind India, Nigeria and South Africa). (1) HIV/AIDS has been responsible for Kenyans losing 18 years in life expectancy, from 65 to its current value of 47 years; (2) and there are estimates that it claims approximately 700 young lives daily. The transmission of the HIV virus from the mother to her infant (MTCT) is an enormous problem; antenatal HIV infection rates range from 8% to 25% in western Kenya. Currently, about 400 000 HIV-positive people in Kenya urgently need treatment with ARVs. Moi University Faculty of Health Sciences (MUFHS), located in western Kenya, includes the country's second med- ical school. The faculty fosters community-based education and service at a number of urban and rural health centres and at Moi Teaching and Referral Hospital (MTRH), a large urban hospital located in Eldoret. Along with their United States collaborating medical schools, Indiana University School of Medicine and Brown Medical School, MUFHS has established an Academic Model of Prevention and Treatment of HIV/AIDS (AMPATH) that provides community out- reach and health education, prevention of mother-to-child transmission of HIV (PMTCT), and treatment of HIV- infected individuals at established clinics at Moi Teaching and Referral Hospital and the affiliated Mosoriot Rural Health Centre (MRHC). The Academic Model of Prevention and Treatment of HIV/AIDS may well be a model of care that can be replicated in countries faced with a similar devastating situation.