Delivering Antiretroviral Therapy in Resource-Constrained Settings

Introduction

"At the United Nations General Assembly Special Session on HIV/AIDS, held in June [2005], the global community cited ART [antiretroviral therapy] as a key component of effective HIV/AIDS programmes. In their Declaration of Commitment, heads of state from countries affirmed that 'prevention, care, support and treatment for those infected and affected by HIV/AIDS are mutually reinforcing elements of an effective response and must be integrated in a comprehensive approach to combat the epidemic.'

Tragically, only a small fraction of the estimated 4 million people living with HIV worldwide has access to the full range of services, including treatment. In Africa, home to approximately 26 million HIV-infected people, only 8 percent of the more than 4 million people clinically eligible for ART (ages 15–49) has access to it. Delivering ART in these settings presents significant challenges related to drug supply, health infrastructure, provider availability and capacity, equitable service provision, and drug adherence, toxicity and resistance.

To address these challenges, FHI [Family Health International], USAID [United States Agency for International Development] and their partners developed ART learning sites in Ghana, Kenya and Rwanda. These countries were identified because of their strong government commitment to provide and sustain HIV treatment, their well-established national AIDS programmes and the presence of ongoing IMPACT [Implementing AIDS Prevention and Care] prevention and care interventions. The objectives were to:

• Improve the capacity of clinics, laboratories and pharmacies in selected health facilities to provide comprehensive HIV services, including treatment;
• Strengthen referral networks to link ART delivery with other care and support services across a continuum of care between health facilities and communities;
• Educate communities, including people living with HIV/AIDS (PLHA), about HIV disease, the need for prevention and treatment of opportunistic infections, when to seek care and the benefits and limitations of ART;
• Provide ART to an initial cadre of patients, ensuring drug adherence, proper management of side effects and toxicity, and regular monitoring and follow-up; strengthen commodity management, including the drug supply chain;
• Explore selected operations research questions, particularly related to adherence and cost;
• Gather and distil lessons to guide service expansion.

In 2002, FHI worked closely with national, provincial, district and municipal leaders, health providers, community-based organisations and PLHA [people living with HIV and AIDS] to conduct assessments, develop and refine treatment guidelines and protocols, build capacity and infrastructure, establish linkages and prepare communities for the introduction of ART. Technical partners included the Institute for Tropical Medicine, Antwerp, and Makerere School of Medicine (clinical training); Management Sciences for Health/Rational Pharmaceutical Management Plus (commodities; laboratory and pharmacy strengthening); and the Population Council/Horizons (operations research).

In 2003, ART learning sites were launched at Atua Government Hospital, Korle-Bu Teaching Hospital and St. Martins de Porres Hospital in Ghana; at Coast Provincial General Hospital (CPGH) in Kenya; and at Biryogo Medical and Social Center (health center) and Kabgayi District Hospital in Rwanda. At each site, ART was introduced as an integral component of comprehensive care and support for HIV-infected patients and their families. In 2004, additional sites opened at hospitals and health centers throughout each country. The sites, operating with USAID assistance in Kenya and Rwanda and with DFID [Department for International Development] assistance in Ghana, are part of closely linked referral networks within defined geographic areas, such as districts or municipalities. By the end of April 2005, more than 5,800 new patients had initiated ART through this treatment and care initiative.

In the two years since the initial learning sites were launched, FHI and its partners have learned valuable lessons that can guide development and expansion of ART services in Africa and other regions. This document presents many of these, along with strategies, challenges and key recommendations. Comments by national and community leaders, providers and patients appear throughout the text to give readers a sense of the programmes as they progressed.

Throughout the text, 'lessons learned' refers to experience that implementers consider valuable for countries initiating ART programs. We recognise that this term is often used loosely in the public health literature, sometimes referring to genuine, new insights, but often validating or reinforcing existing best practices. However, the programmes described in this document were launched at a time when extensive ART provision was considered infeasible in resource-constrained settings. There were few models to follow — none for programmes involving the public sector and attempting to link communities with facility-based efforts. Thus, 'lessons learned' applies most closely to the material contained herein.

The document is intended for governments, development partners and public and private health facilities seeking to integrate ART into existing HIV services. The lessons may not have direct relevance to all health facilities providing or planning to provide ART; they should be used or adapted depending on the epidemiological, political, social, cultural and economic context of each setting. The document is divided into nine chapters, each addressing an essential element of an effective ART programme:

• Chapter 1. Country Preparedness
• Chapter 2. Community Preparedness
• Chapter 3. Site Preparedness
• Chapter 4. Referral Systems and Linkages
• Chapter 5. Patient Preparation and Adherence
• Chapter 6. Health Management Information Systems
• Chapter 7. Scale-up
• Chapter 8. Patient Response to ART
• Chapter 9. Operations Research

FHI staff hope this document will contribute in a meaningful way as national programs and global initiatives - such as the President's Emergency Plan for AIDS Relief, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the World Health Organization 3 by 5 Initiative - make new resources available for HIV treatment."