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Jack Killen, MD Comments On the Future of HIV/AIDS Research

Summer 2001

Jack Killen, MD: Director, Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health

The XIII International AIDS Conference, held last July in Durban, South Africa, marked a sea change in attitudes and beliefs about treatment of HIV-infected people in the developing world. A remarkable cascade of events, unimaginable even a year ago, is now unfolding. There have been dramatic declines in drug prices, public and private sector agencies are mobilizing to plan and implement pilot care programs, and governments are making real financial commitments. These efforts are tremendously exciting and deserve vigorous and universal support.

While well-intended, the public focus on drug prices has obscured the real barriers to care for people with HIV in the developing world -- severely inadequate health care systems and infrastructure, and too few trained people to work in them. In other words, even if drug pricing was not an issue in the hardest hit developing countries, the health care systems are not there to deliver them.

The following anecdote is illustrative. In March, I visited a small rural health center in Uganda, near the Tanzanian border. It was staffed by a nurse/health officer and a midwife. We asked the midwife what she does when she has a difficult delivery. She told us that she sends the woman to the regional hospital, located about 20 kilometers down a muddy, rutted, dirt road. Transportation, when she has gasoline, is by motor scooter; if not, by bicycle. (I was told that 70% of the population of Uganda live more than ten kilometers from such a health facility.) We also visited the regional hospital. I counted at least 80 people waiting to see one of the three staff physicians; children shared beds and adults slept on the floor or outside; the laboratory staff used alcohol lamps, manual blood counting equipment, and a hand-cranked centrifuge to spin down blood. In the bigger picture, it is vital to remember that a top health priority of the country is ensuring clean water for the entire population; it is a little more than half-way there.

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This is the context -- and it is the rule, not the exception -- in which medical care in the developing world must be delivered. The appalling inequality of health care around the world is tragic and not in any way unique to HIV/AIDS (though there are certainly many unique HIV/AIDS problems). Nonetheless, it is the enormity of the chasm between here and there which explains why so little has been done for care of people with HIV infection in the developing world. These are daunting obstacles which must be overcome.

Any formula aimed at making even a dent in the problem of HIV care in the developing world must include the following:

  1. capacity to provide basic health care must be built, not just for people with HIV disease, but for all;

  2. ongoing HIV prevention programs must be preserved, expanded, and integrated with care initiatives;

  3. research attempting to identify sustainable care in developing world settings must be initiated;

  4. in-country research capability, both human and infrastructure, must be built; and

  5. the genuine moral dilemmas behind many significant ethical problems must be evaluated with care and reason. Tactically, unprecedented levels of public and private collaboration and cooperation must be brought to bear, since it will be essential to leverage resources from various sectors and countries. It will also be necessary to take the long view, aiming toward incremental steps forward through pilot programs and innovative approaches to treatment.

If we have learned one thing in the twenty years of this epidemic, it is that HIV highlights hidden or ignored generic social problems and points the way to their resolution. We must not be overcome by the enormity of the challenge ahead, but use the current situation as a leverage point to bring about change in the quality of all health care for those in the developing world. It is long, long overdue.





  
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This article was provided by AIDS Community Research Initiative of America. It is a part of the publication CRIA Update. Visit ACRIA's website to find out more about their activities, publications and services.
 

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