Academic journal article Bulletin of the World Health Organization

Prevention and Treatment of Human Immunodeficiency Virus/acquired Immunodeficiency Syndrome in Resource-Limited settings/Prevention et Traitement Du VIH/SIDA Dans Les Pays a Ressources limitees/Prevencion Y Tratamiento del VIH/SIDA En Entornos Con Recursos Limitados

Academic journal article Bulletin of the World Health Organization

Prevention and Treatment of Human Immunodeficiency Virus/acquired Immunodeficiency Syndrome in Resource-Limited settings/Prevention et Traitement Du VIH/SIDA Dans Les Pays a Ressources limitees/Prevencion Y Tratamiento del VIH/SIDA En Entornos Con Recursos Limitados

Article excerpt

Introduction

Strategies for confronting the epidemic of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/ AIDS) have included a range of approaches that focus on prevention and treatment. However, debate persists over the degree of emphasis appropriate to the different components of the global response to the pandemic. Outside wealthy countries, most of the public health interventions for HIV/AIDS have concentrated on prevention. More recently, expansion of antiretroviral therapy (ART) to resource-limited settings has gained prominence as a topic of international debates on HIV/AIDS. In December 2003, WHO launched an initiative to scale up ART delivery to those in need to meet the "3 by 5" target of 3 million people receiving treatment by the end of 2005.

In this paper, in the context of resource-limited settings, we summarize the debate over ART expansion and the evidence on the effectiveness of prevention strategies, especially those interventions likely to be most prominent in efforts to integrate prevention and treatment. We then review the experience gained thus far with ART in resource-limited settings and consider areas of research that may advance the global response to HIV/AIDS.

Evolving paradigms

Efforts to reduce HIV transmission have varied in focus as competing prevention paradigms have captured the interest of decision-makers and funding agencies. Early in the epidemic, an emphasis on "core groups" of transmitters led to prevention efforts being directed towards female sex workers, men who have sex with men (MSM) and intravenous drug users (1). As attention has broadened to include risk behaviours in the wider community, particularly in generalized epidemics such as that in sub-Saharan Africa, more recent debates have revolved around the scope and focus of prevention strategies. The central role of condoms in controlling HIV has been questioned by proponents of the "ABC" approach, which gives priority to "A" (abstinence) and "B" (being faithful) over "C" (condoms) (2). Arguments, put forward primarily by the US Government, for an abstinence-only educational message have been repudiated on scientific grounds, and opponents have cautioned against politicizing school-based education strategies (3).

Although the importance of risk groups and risk behaviour is widely recognized, frustration over limited progress in reducing the incidence of HIV worldwide has bolstered the view that social vulnerability and stigma may hinder the effective implementation of prevention programmes. Calls for treatment as a means to enhance prevention, however, have been accompanied by contentious international debates over scaling up ART in resource-poor settings.

The reservations about the expansion of ART have revolved around the practical challenges of implementing treatment programmes and the high costs of the drugs. In consideration of the severe constraints on human resources in many developing countries and the limited capacity to monitor CD4 cell counts and viral loads, those urging caution in scaling up ART have pointed out that inadequate oversight and care could lead to negligible improvements in survival coupled with the development of drug resistance (4, 5). Opponents of ART expansion have frequently used arguments related to cost-effectiveness, suggesting that greater health gains could be realized for a given financial investment if it were devoted to prevention rather than treatment. For example, one study estimated that ART would cost US$ 1100-1800 per disability-adjusted life year (DALY) averted, whereas preventive interventions such as voluntary counselling and testing (VCT) or condom distribution would cost US$ 18-22 and US$ 1-99 per DALY averted, respectively (6). Another study concluded that the cost of treatment was at least 28 times higher per DALY averted than that of average prevention programmes (7). Although pressure from advocacy groups and the advent of generic drugs have reduced the costs of antiretrovirals precipitously, from more than US$ 10 000 to as low as US$ 140 per patient-year (8), some cost-effectiveness differential between prevention and treatment is likely to persist (6). …

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