The global movement to reduce the price of medicines and expand access to antiretroviral Therapy (ART) continues to gather momentum. In sub-Saharan Africa, the region with the highest number of people living with AIDS, millions of dollars are being directed at this cause through governments and the Global Fund to Fight AIDS, tuberculosis and malaria. Ensuring access to treatment is a human right. It is important that attempts to provide a comprehensive response to the HIV epidemic, including access to drugs, are fully supported.

However, there are a number of inadequately acknowledged pitfalls associated with the push to rapidly expand access to ART in this region. Unless the push to expand access to ART is placed within the context of comprehensive health systems development, it may fail to achieve the desired aim of reducing AIDS-related mortality.

The provision of ART treatment provides a great opportunity to save and improve the lives of many thousands of people. It also presents the challenge of developing a high quality, equitable and sustainable delivery system. This article outlines some of the pitfalls that could result from the need to meet treatment targets and suggests ways in which these could be avoided.

Possible implementation pitfalls

Initiatives to deliver ARTs as widely and quickly as possible, need to recognise and address the risks of entrenching or even increasing inequity, the limitations of poor public health infrastructure and capacity, communities and NGOs bypassing the public health system, evolving ART resistance, and the potential of over-medicalising the response to HIV/AIDS.

Increasing inequity

It is important to recognise the health systems risks associated with efforts to rapidly expand access to ART. If they are not part of the broader health systems development process, inequities between different parts of the country and different health programmes may be worsened.

There is already evidence that the implementation of ART treatment programmes has widened geographical inequities in the availability and types of HIV care offered. In urban areas thousands of HIV clients are being placed on treatment but many in rural areas still do not have access to basic voluntary counselling and testing. Resources such as doctors, laboratory services etc will remain scarce if the extra resources for ART treatment are focused in the large urban settings as it is presently.  

The poor access to, and quality of, health care in low-income communities leads to poor households taking on larger burdens of care for people dying of AIDS. This further reduces the health status and economic capacity of these households. Extra resources made available for the ART programme may occur at the expense of other health programmes in an already under-resourced health care system.

Most importantly it may attract senior and mid-level managers as well as doctors required for ART protocols, away from other important health programmes. There is also a danger that the wider availability of ARTs will focus too much attention on those with HIV who are sick enough to qualify for these drugs at the expense of providing services and interventions to the many other HIV infected people who are either asymptomatic or not sick enough to require ARTs. There are many cost-effective interventions that enable such people to prolong the time before they become sick enough to require ART treatment.

Health system infrastructure and capacity

The HIV treatment programme presents extra challenges to the fragile public health system. The treatment protocols require skilled health workers with access to high quality laboratory services both of which are scarce in many parts of the country. HIV now needs to be conceptualised as a chronic disease that requires continuity of care within the health system throughout the lifetime.

This is especially the case for those on ART treatment where the risk of drug resistance is high (With less than 90% adherence to drug regimes, this risk is substantial). High levels of stigma and discrimination towards those with HIV and AIDS makes continuity-of-care even more difficult.

Finally, there is a massive HIV-induced increase in workload as hospital admissions related to HIV/AIDS exceed 50%. This is complicated by rising rates of infection among health workers. A recent HSRC survey estimated that 16% of primary health care workers were HIV positive, which adds to the strain of the additional HIV workload, inadequate pay, poor support and high job stress.

Bypassing the health system

Growing frustration with the slow progress of the ART roll-out could also lead to people bypassing the public health system and relying more on NGOs, employers and the private sector to deliver this treatment. But this would be a mistake for a number of reasons. Firstly, it is only the public sector that can reach the large number of people that require treatment. Secondly, the public sector is essential for the equitable expansion of treatment to reach the most disadvantaged. Thirdly, a strengthened health system could also provide wider support and services for a more comprehensive HIV programme.

Drug resistance

The stakes are very high for the ART programme. There is huge unmet demand and strong pressure to attain targets so temptation to take clinical and management short cuts is strong. This could result in mono-therapy, dual-therapy regimes or intermittent and interrupted regimes being common, especially in poor communities. Together with poor treatment compliance, this could lead to ART resistance. And despite the decline in the price of first line treatment drugs, second and third line drugs remain costly. Health managers may be tempted to develop vertical systems that focus only on the provision of treatment.

Over medicalisation

Finally, the current focus on antiretroviral therapy could also over-medicalise the response to HIV/AIDS and divert attention and funds away from the more fundamental political, social and economic determinants of poverty and the AIDS pandemic. While the attraction towards a ‘€˜magic bullet’€™, or technological solution, is understandable, stopping the AIDS pandemic requires a broad, multi-sectoral response to the disease, including its underlying social and economic causes.

Lessons from other large health programmes

To avoid such pitfalls we can learn from previous attempts to implement large-scale public health programmes. The Integrated Management of Childhood Illnesses (IMCI) and tuberculosis (TB) programmes provide several important lessons with relevance to ART rollout in South Africa.

A health systems approach to HIV interventions would emphasis integrating HIV with TB, STD and community health programmes. It would ensure ART rollout strengthens other chronic health programmes such as those for diabetes and hypertension. This includes locating ART delivery within the District Health System, supported by effective management structures to provide basic services for HIV and non-HIV related illness in an integrated and locally appropriate manner.

It is essential for large scale ART programmes to have visionary leadership to (a) develop a national strategic framework for prevention, care and treatment; (b) build coalitions with agreed objectives and strategies; (c) formulate rules and incentives to ensure quality care; and (d) provide oversight of the programme across the health system.

Adequate funding for staffing and other critical resources is fundamental for programme success. Poor human resources capacity development and support is perhaps the biggest barrier to implementing health programmes.

An effective health information system integrated into the district health information system and sensitive enough to inform leadership decisions about ongoing treatment requirements, programme access, coverage, quality of services and health outcomes, and operations research is essential.

The support of community health workers, volunteers and community mobilisation is essential to achieve the health promotion strategies and to confront HIV stigma and discrimination.

Avoiding the Pitfalls

We can now sketch out some of the activities necessary to strengthen the capacity of health departments or ministries to ensure synergy between ART programmes and policies within a comprehensive health systems development process. These include

• Realistic targets for ART coverage set in conjunction with realistic and appropriate targets for the delivery of other key essential health care services.
•  Advocacy to increase funding not just for HIV services but for strengthening the public health system in general
• Strengthening public sector management systems to absorb, use and track financial resources
• Establish mechanisms for conditional or emergency fund transfers to be transparent and time bound with plans for their integration into regular budgets and comprehensive health plans.
• Treatment policies and programmes located within a continuum of strategies for prevention, treatment, care and mitigation of AIDS, and within a primary health care approach.
•  Development of innovative ways of recruiting, retaining and capacity-building of health personnel and make better use of health personnel
• Increasing the capacity of community-based organisations to support the ART programme but within the context of broader HIV prevention and treatment activities.
• Continual monitoring and evaluation not just of the functioning and effectiveness of the programme but also of coverage and access across the country.
• Operational research to learn from sites that are performing well and to evaluate innovative strategies

Conclusion

Activists, practitioners and researchers have successfully collaborated to make the treatment of HIV a reality. If the fruits of this massive achievement are not to be short-lived and only enjoyed by a minority then it is imperative that we now use this opportunity to develop a high quality, equitable and sustainable delivery system. This article has argued that this can be best accomplished through strengthening the existing public health system. To achieve this successfully will require leadership, capacity development and partnerships between government and civil society.

* Dr Mickey Chopra is a senior lecturer, School of Public Health, University of the Western Cape.

Critical Health Perspectives is a publication of the Peoples Health Movement-South Africa   (PHM-SA). However, the views expressed here do not necessarily reflect the view of all those who have identified with PHM-SA. For further information see: http:///www.phmovement.org