[procaare] Comprehensive Health Care for PLWHA in Developing Countries

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Comprehensive health care for people infected with HIV in developing countries
BMJ 2002;325:954-957 ( 26 October )
http://bmj.com/cgi/content/full/325/7370/0/c
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Mari M Kitahata, director of health services research a, Mary K
Tegger, healthcare specialist a, Edward H Wagner, director b, King
K Holmes, director a

a Center for AIDS and STD, University of Washington, Harborview
Medical Center, Box 359931, 325 9th Avenue, Seattle, WA 98104, USA, b
MacColl Institute for Health Care Innovation, Center for Health
Studies, Group Health Cooperative of Puget Sound, Seattle, Washington
Correspondence to: M M Kitahata kitahata@u.washington.edu

By far the greatest burden of disease from HIV infection is in
developing countries, where health services are generally ill
equipped to cope.

The authors consider how effective HIV services can be delivered in
such countries

HIV infection poses tremendous challenges to healthcare systems
globally. Over 90% of the estimated 40 million people living with HIV
infection in 20011 live in resource poor settings and do not share
the improved prognosis now achieved in developed countries.2 The
World Health Organization estimates that in 2002, of the 6 million
people in developing countries in need of antiretroviral therapy,
only 4% are getting such treatment, half of whom live in Brazil.2 In
2001 about 900 000 people were infected with HIV in the United States,
and over 500 000 (over 55%) were receiving antiretroviral therapy.1
In sub-Saharan Africa, however, of the more than 28 million people
with HIV infection in 2001, fewer than 30 000 (just over
0.1%) were receiving antiretroviral therapy.1 In 2001, there were
about 15 000 deaths from AIDS in the United States (roughly 1.7%
annual mortality) and an estimated 2.2 million deaths from
AIDS in sub-Saharan Africa (over 7.9% annual mortality).1 In this
article we explore the question of how effective HIV services can be
delivered in resource poor countries.

Summary points

Universal access to comprehensive health services is needed to
reduce HIV related morbidity and mortality worldwide

The World Health Organization's strategy for chronic disease
management in resource poor countries could provide a model for
delivering comprehensive services to people infected with HIV
who have similar healthcare needs

Developing effective communication and referral systems to
closely link primary providers to more specialised HIV services could
start to address the need for HIV expertise

Integration and coordination of services could optimise the use
of resources and increase access to HIV care

Health services research is needed to define the most effective
ways to develop a comprehensive system of HIV care

Partnerships between donors, governments, non-governmental
organisations, and local organisations are essential for developing
effective and sustainable HIV and AIDS prevention and care programmes

Methods

We performed searches of Medline, AIDS databases, and global HIV and
AIDS libraries such as Joint United Nations Program on HIV/AIDS
(UNAIDS) publications and website, and we reviewed abstracts of major
AIDS conferences including the XIV International Conference on AIDS
in Barcelona, July 2002. We also relied on personal experience,
research, and capacity-building activities of members of the faculty
affiliated with the University of Washington Center for AIDS Research
who are funded by the National Institute of Health, US Agency for
International Development (USAID), WHO, Centers for Disease Control
and Prevention, and Health Resources and Services Administration for
work in Africa, the Americas, and Asia.

Comprehensive health services for HIV care and prevention

Universal access to comprehensive health services is needed to reduce
substantially HIV related morbidity and mortality worldwide. These
services must effectively address six needs:

Voluntary and confidential counselling and testing for HIV infection
Prevention of HIV transmission, including sexual, parenteral, and
mother to child transmission
Prophylaxis against opportunistic infections
Diagnosis and treatment of HIV related conditions including
opportunistic infections and neoplasms
Antiretroviral treatment
Palliative care.

Developing countries will have to develop healthcare system
infrastructures capable of delivering these services, including
skilled health providers and laboratory facilities, HIV related
training programmes, aligned national and local government policies,
and a capacity to do operational research to improve care.

WHO strategy for chronic disease care in the developing world

Many non-communicable chronic diseases also are increasing in
developing countries as rapid improvements in health and longevity
have changed the burden of illness.3 Although HIV infection has
dramatically lowered life expectancy in much of sub-Saharan Africa,
life expectancy in most developing countries has continued to
increase over the past decade.4 It is estimated that half of all
health services required in developing countries are for chronic
conditions such as diabetes and cardiovascular disease.3 To address
this epidemic, the WHO recently proposed a global strategy to
design and reconfigure healthcare systems to better meet the needs of
people with chronic illnesses (see box).

WHO strategy for comprehensive chronic disease care in the developing world

Shift emphasis from acute, episodic care to provide continuity of
care with planned visits and regular follow up

Develop health policies, collaboration, legislation, and healthcare
financing to support comprehensive care strategies

Emphasise delivery of services at primary care level to assure
broadest access to effective care

Develop effective communication and referral systems between primary,
secondary, and tertiary levels of health care

Centre care on the patient, educate patients about their disease so
they can become active participants in their care, and promote
adherence to long term treatments

Link care to community resources; provide education and support to
family and community members to assist in care

Emphasise prevention

Monitor and evaluate the quality of services and long term patient
outcomes

The WHO strategy could provide a model for delivering comprehensive
services to people infected with HIV, who have similar healthcare
needs.6 However, the medical management of HIV infection and
antiretroviral treatment with regard to drug toxicity, metabolic
complications, adherence to treatment, and emerging viral resistance
is complex and may require a higher degree of expertise than do many
other chronic conditions. In settings where combination
antiretroviral therapy based on protease inhibitors and non-
nucleoside reverse transcriptase inhibitors is widely
available doctors with expertise in treating HIV deliver more
effective antiretroviral treatment.7 More experienced doctors achieve
better patient outcomes, including longer survival, than doctors
who are less experienced in providing HIV care.8 Access to such
expertise in developing countries will be a critical challenge.

Demands of effective antiretroviral treatment

International efforts are improving access to antiretroviral drugs
with the aim of making antiretroviral treatment available worldwide.2
The enabling infrastructure needed to deliver treatment includes
policies, negotiated drug price structure, drug purchasing, storage
and distribution systems, and development of treatment guidelines and
training programmes. Additional aspects of providing
antiretroviral therapy include identifying who is infected and which
infected people would most benefit from treatment 2 9 ; assessing
disease stage9 and monitoring response to treatment in the
absence of ready access to measurements of CD4 cell count10 and viral
load or resistance testing; managing drug toxicity; maintaining high
levels of treatment adherence required to suppress viral
replication and prevent development of drug resistance; and deciding
when to change a failing treatment regimen and what drugs to use in
the subsequent regimen.

Because antiretroviral resistance emerges not only to a particular
antiretroviral drug but also to other drugs in the same class, a
limited number of effective regimens can be constructed despite the
increasing number of antiretroviral drugs available. Prior use of
short course antiretroviral drugs by HIV infected women to prevent
mother to child transmission might lead to drug resistance and
limit future treatment options.11 Serious toxicities associated with
some antiretroviral drugs include hyperlipidaemia, insulin
resistance, diabetes, lactic acidosis, and pancreatitis.

Antiretroviral treatment for specific subpopulations in developing
countries is complicated by drug interactions among HIV infected
patients taking antituberculous drugs12 and higher risk of hepatic
toxicity among patients co-infected with hepatitis viruses.13 Up to
70% of HIV infected people in developing countries are co-infected
with tuberculosis,14 and high rates of hepatitis C and hepatitis B co-
infections exist in many parts of the developing world. Strategies to
identify and address adverse antiretroviral treatment events and
viral resistance in developing countries are emerging
(WHO/International AIDS Society global HIV drug resistance monitoring
project).

Defining services at different levels of health care
The WHO strategy for providing comprehensive care to people with
chronic diseases emphasises the importance of defining services
delivered at each level of health care, from home care, to
community level participation, and to primary, secondary, and
tertiary levels of service delivery.3 Delegating roles and
responsibilities for specified services to less skilled staff,
training primary care providers to deliver some aspects of HIV care,
and developing effective communication and referral systems to
closely link primary providers to more specialised HIV services could
begin to address the need for HIV expertise in resource poor
settings. Specially trained HIV providers located at regional health
centres or hospitals could provide consultation, management of HIV
related conditions, laboratory testing and monitoring, and training
for primary care providers. Primary care teams could be trained to
carry out clearly defined tasks such as treatment adherence
counselling, supporting patient self management, and providing
counselling and testing, prevention services, and palliative care in
the community.

Coordination of services
Integration and coordination of services are important elements of
the WHO chronic disease model that could optimise the use of
resources and increase access to HIV care. Counselling and testing
services are key components of HIV care and preventing HIV
infection,15 but the limited services that do exist in developing
countries are concentrated in urban areas, whereas most people in
Africa and Asia live in rural areas. Thus, most people at risk of HIV
infection remain unaware of their HIV status.15

The availability of counselling and testing services could be
expanded, particularly for women, by integrating these services into
existing vertical programmes such as antenatal care, family planning,
and maternal and child health programmes and by linking counselling
and testing with HIV prevention programmes. Integrating counselling
and testing services with family planning and antenatal care
is critical for preventing mother to child transmission. Training HIV
prevention workers to perform counselling and testing and making
rapid HIV testing technology available will help increase access
to such services. In turn, HIV testing should serve as an entry point
into HIV care, as in Uganda, where counselling and testing services
provide access to antiretroviral treatment and referral to
other AIDS services.1

Wider access to HIV care could significantly increase the number of
people who seek testing and therefore receive essential prevention
counselling.16 HIV care has been successfully linked with
HIV prevention programmes in Thailand, Cambodia, Uganda, and Senegal.
1 17 Brazil is regarded as a leading example of the integration of
HIV care and a renewed commitment to prevention.18
Although the provision of government funded antiretroviral drugs has
increased access to antiretroviral treatment in Brazil, the extensive
HIV treatment and care programme operating in Brazil and
other parts of Latin America might be less applicable to countries
with a larger proportion of their HIV infected populations living in
rural areas with weaker transportation systems.18

Customising models of healthcare delivery
Different models of healthcare delivery will be needed to respond to
the diverse requirements for establishing comprehensive HIV care in
developing countries. The Pan American Health
Organization/WHO, in collaboration with the United Nations Joint
Program on HIV/AIDS (UNAIDS) and the International Association of
Physicians in AIDS Care, has proposed a phased-in
"building blocks" approach to delivering the health services required
for comprehensive HIV care,19 which shares key elements with the WHO
model for chronic disease management. In this
approach, the complexity and sophistication of services provided at
each level of health care would depend on the availability of
technical and financial resources, skilled providers, and healthcare
infrastructure in a given setting.

Integration and coordination of services is needed to optimise use of
scarce resources for HIV care

The implementation of basic services would provide the foundation for
delivering more specialised services. As resources increase, the
range and specialisation of services provided at each level of
care could increase. For example, a setting may have sufficient
resources to train providers to manage counselling and testing and
prophylaxis against opportunistic infections at the primary care
level, prevention of mother to child transmission and the diagnosis
and treatment of opportunistic infections at the secondary level of
care, and antiretroviral treatment at the tertiary level. With the
availability of more sophisticated tools, training, and supportive
infrastructure, the antiretroviral treatment and management of
opportunistic infections might prove feasible and effective at more
peripheral levels of care, out to the primary care level.

The WHO has also proposed an approach to scale up antiretroviral
treatment in developing countries that includes the use of
standardised antiretroviral drug regimens.2 This approach could enable
primary care providers with basic training in HIV care to provide
algorithm guided antiretroviral treatment with the help of evidence
based guidelines for monitoring drugs' side effects and toxicities.
Providing components of HIV care at the primary health care level
would be essential to reach most of those infected, but experiments
in healthcare delivery are needed to define what services can
be delivered at the primary care level that will improve long term
patient outcomes.

Need for research
Health services research is needed to define the most effective and
efficient ways for countries to move from their current state of
healthcare provision to developing a comprehensive system of HIV
care. This research must address questions such as whether and to
what extent standardised approaches to antiretroviral treatment and
treatment of opportunistic infections decrease HIV related
morbidity and mortality, what approaches to providing patient and
family support improve adherence to drug regimens, and how best to
integrate education and counselling on prevention at patient
and community levels. Studies of adherence in resource poor settings
have shown that monitoring programmes involving home visits can help
patients attain high levels of adherence.20 Designing
these services must include the perspectives of people infected with
HIV.

Imposing chronic disease management strategies on existing systems of
care that are organised to address acute episodic illness is unlikely
to be successful. HIV care, like that of other chronic
illnesses, requires planned visits and regular follow up. Delivering
care for other chronic communicable diseases such as tuberculosis
shows the need for close follow up, prevention of antimicrobial
resistance, and the effectiveness of directly observed treatmentand
such lessons can help guide the care of people with HIV infection and
AIDS. A community based model developed in Haiti
used existing tuberculosis control infrastructure to deliver
antiretroviral treatment to symptomatic patients.21 This programme
made effective use of community health workers who provided patient
support and education and gives anecdotal evidence of symptomatic
improvement among small numbers of patients receiving antiretroviral
treatment.21 Research is needed to confirm the impact on
various health outcome measures, including survival, of guideline
based approaches to antiretroviral treatment in resource poor
settings. Ongoing evaluation and monitoring of clinical outcomes is
essential.

Need for partnerships
The global epidemic of HIV infection and AIDS continues to spread,
and the number of people living with HIV infection continues to
increase, with five million new HIV infections and three million
deaths from AIDS in 2001. The numbers living with AIDS will probably
increase further with effective deployment of HIV care, particularly
if prevention efforts are not strengthened concurrently.1
Partnerships between donors, governments, non-governmental
organisations, and local organisations are essential in developing
effective and sustainable prevention and care programmes. Policy
statements (such as those made by the United Nations General Assembly
Special Session on HIV/AIDS, 2001 22 23 ), various guidelines, 2 19
and international training initiatives (including the
CDC/HRSA International Training and Education Center on HIV
programme, the International AIDS Society training programme, the
Academic Alliance for AIDS Care and Prevention in Africa,
and the Regional AIDS Training Network in Kenya) must coordinate
their training messages and seek compatible, practical models for
care delivery. A policy environment in which all sectors of
society play a part in addressing the AIDS epidemic is crucial for
success. Experience with the WHO care model for chronic diseases may
help inform the design of healthcare systems to provide
comprehensive care for HIV infection in developing countries, and
coordination between these efforts would likely benefit both
initiatives.

Footnotes

Funding: This work is supported by the University of Washington
Center for AIDS Research NIAID Grant (AI-27757) and the Mentored
Patient-Oriented Research Career Development Award
NIAID Grant (AI-01789).

Competing interests: EHW was guest editor for this theme issue. KKH
has received consulting fees, research funds, and reimbursment for
attending a symposium from manufacturers of drugs to
treat AIDS.

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© BMJ 2002

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