Pierre Dijiba, MD  Medical Director from Senegal

  Prior to the year 2000, the high cost of anti-retroviral drugs placed HAART beyond the budgets of most governments, NGOs, and patients in poor countries. In countries where yearly per capita incomes are below $1000, only the rich could afford the $15,000 annual price tag for HAART. Now that pharmaceutical firms have agreed to lower the prices they charge for ARVs in poor countries and as more funding becomes available from sources such as the U.N. Global AIDS and Health Fund***, HAART may soon become more widely available to people living with HIV/AIDS in those nations. Access to affordable drugs is important, but so is having adequate medical infrastructure to distribute the drugs and monitor patients' reactions to them.

    As Dr. Stansky remarked, medical infrastructure varies widely between African nations. Compared to many of its neighbors, Botswana* is a wealthy nation. Patients are served by a well-developed and expanding medical infrastructure including trained staff, clinics, hospitals, and laboratories. Poorer nations, such as Malawi* are not yet equipped at this level. However, physicians with the NGO, Partners in Health,* working in Haiti, the poorest country in the Western Hemisphere, have shown that HAART can be provided under extremely difficult conditions. Conditions that are not unlike those faced by patients and staff in many African nations like Malawi, including: bad roads, lack of laboratory equipment, unreliable electrical supplies, and extreme poverty.

    At the Haitian clinic, they do not have access to laboratories that can perform the tests to check a patient's CD4*** cell count and viral load***. These tests indicate the state of a patient's immune system and are used to decide if a patient should begin HAART in the United States and other countries. Instead, they base their decision to initiate HAART on a list of easily observable signs and symptoms.*  I believe that we could use similar criteria at our clinics in Africa thus avoiding an immediate need to purchase very expensive medical equipment and supplies. In a country like Botswana facilities may be available to perform these tests and whenever possible, we should forge partnerships with hospitals and laboratories equipped to perform them. In nations such as Malawi, the guidelines developed in Haiti could be utilized in lieu of these lab tests until such time as they become available.

    In my opinion, the people that we should treat first at our clinics are those patients who are no longer responding to treatment for opportunistic infections, that is, the patients with the greatest medical need for HAART. As they have found in Haiti, many HIV positive patients do quite well without HAART if they receive effective treatment for their opportunistic infections. As we apply for funding, I suggest that we also seek aid to expand treatment for these infections. I do not believe that patients should receive HAART because they are "elite" government officials** or soldiers as some people have suggested.

   How many people should we treat? I believe that Dr. Corelli's proposal for an initial group of 50 patients per clinic is a good place to begin. This number will not overload our capacity, but will give us the opportunity to learn how to provide this therapy correctly in each of our clinics. Remember, once this therapy is begun, a patient is expected to continue it for the rest of his or her life.

    And finally, with regard to the method of delivering treatment to patients, I would again look to Haiti. They have been employing Directly Observed Therapy or DOT. Each day medical personnel or a trained community health worker observes each patient as he or she ingests the pills. Treatment can be delivered to a patient's home or workplace. In this way, adherence* to the dosing schedule* is ensured without disrupting patients' daily lives. This is crucial since we know that HAART is most effective when patients take their medications correctly at least 90% to 95% of the time. I feel certain that Nurse Khosa and her colleagues would be able to assist us in delivering treatment to patients in the communities where they live.

*=Essential
**=Greater Depth
***=Advanced Knowledge