Community-Based Approaches to HIV Treatment in Resource-Poor Settings

AIDS mortality has dropped precipitously in affluent countries, in large part because of access to highly active antiretroviral therapy (HAART). The main objections to the use of these agents in less developed countries have been their high cost and the lack of health infrastructure necessary to use them. However, the authors have demonstrated that it is possible to carry out an HIV treatment program in a poor community in rural Haiti, the poorest country in the Western Hemisphere. Relying on an already existing tuberculosis-control infrastructure, the researchers have been able to provide directly observed therapy with HAART (DOT-HAART) to about 60 patients with advanced HIV disease. In this report, the researchers discuss objections to the widespread use of HAART, and suggest that directly observed therapy of chronic infectious disease with multi-drug regimens can be highly effective in settings of great privation as long as there is sustained commitment to uninterrupted care that is free to the patient.

Haiti is by all conventional criteria the poorest country in the Western hemisphere and one of the poorest in the world. Not coincidentally, Haiti is also the hemisphere's most HIV-burdened country. In 1999, UNAIDS reported national HIV seroprevalence as 5 percent among women attending antenatal clinics -- rates were twice as high in urban slums. Shortly after the publication of the ACTG-076 trial, the researchers began offering zidovudine to pregnant women to block mother-to-child transmission. More than 90 percent of women offered HIV testing accepted it after zidovudine was made available free of charge, and dramatic declines in vertical HIV transmission ensued. In 1997, the researchers began offering post-exposure prophylaxis with a three-drug regimen (usually zidovudine, 3TC, and a protease inhibitor) to victims of rape or professional injury. Beginning in late 1998, a small number of patients with long-standing HIV disease who no longer responded to syndromic treatment of opportunistic infections were offered directly observed HAART.

In the clinic, DOT-HAART is modeled on successful tuberculosis-control efforts. That is, each HIV patient has a community-health worker who observes ingestion of pills; responds to patient and family concerns; and offers moral support. Response to HAART in an initial cohort of 60 patients has been dramatic. As elsewhere, patients receiving HAART are far less likely to require admission to the hospital than are patients with untreated HIV disease. "We believe that if DOT-HAART can be implemented in the devastated Central Plateau of Haiti it can be implemented anywhere," the researchers wrote.

The two primary objections to use of HAART in poor communities have been the high costs of the medications and the lack of infrastructure necessary to deliver them effectively. However, several firms, including one based in India, have developed very low-cost formulations of zidovudine, 3TC, D4T, ddI, and nevirapine. The effective treatment of multidrug-resistant tuberculosis (MDR-TB) in impoverished regions may offer important lessons. Working in rural Haiti and in a slum in Lima, Peru, the research group pioneered a community-based strategy to treat MDR-TB. Using strict DOT and the same standards of care as in tertiary medical centers in the United States or Europe, the researchers achieved results better than those reported in industrialized countries. Patients tolerated drug regimens more complex and far more toxic than HAART, with low rates of abandonment. The authors called this approach "DOTS-Plus," because it incorporates the managerial strengths of the DOTS strategy but relies on drug-susceptibility testing to determine treatment regimens appropriate for each patient. This strategy is now being replicated in the former Soviet Union, where MDR-TB constitutes a growing problem. The researchers believe that much of the policy debate regarding the role of HAART in responding to AIDS has been misguided. In sub-Saharan Africa and Haiti, where HIV is the reason for plummeting life expectancies and for increasing numbers of orphans, the authors discern fairly overt obstructionism to the use of HAART. HAART has already been declared cost-effective in Europe, North America, and even Brazil, where HIV has become, for many, a chronic infection.

"We know from experience that repeated claims of unfeasibility are simply not true. Multiple research projects carried out in sub-Saharan Africa have shown that more-developed world diagnostic tests can be used to follow viral load and to reveal the genotype of drug-resistant strains of HIV. It is time that more-developed world therapeutics follow," the authors concluded.

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