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July 2003 Public Health HIV/AIDS Journal Club
Judith King. HIVAN Media Team.
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Anti-retroviral treatment, particularly the scale-up of programmes and their impact on public health-care systems, was the theme of two presentations given at the July 2003 Public Health HIV/AIDS Journal Club, held at the Nelson R Mandela School of Medicine, University of KwaZulu-Natal.
Community Health specialist Dr Robert Pawinski, of the Enhancing Care Initiative, spoke on a recent journal article entitled "Predicting the public health impact of antiretrovirals: Preventing HIV in developing countries" by Sally Blower (of the AIDS Institute and Department of Biomathematics, David Geffen School of Medicine University of California at Los Angeles) and Paul Farmer (of the Program in Infectious Disease and Social Change, Harvard Medical School, Partners In Health, Boston, Massachusetts, US).
Pawinski summarised the key points of the paper, explaining that the study used mathematical models with ARV for prevention and resistance in examining the public health impact of ARV treatment in both developed and developing countries. The recommendation of ARV therapy, not only as a treatment modality, but also as a secondary, preventative tool, was informed by the prevailing debate of "mega"-funding favouring either prevention OR treatment and care. The predictions extrapolated from the findings of this study included a potential reduction in mortality and HIV transmission, lowered viral load in HIV-positive patients and improved access to health care (including monitoring, which would decrease the chances of adherence drop-off and concomitant development of ARV-resistance).
Other benefits would be better dissemination of information on risk behaviour and improved health worker morale. Andy Gray, from the Department of Experimental and Clinical Pharmacology, commented that although no data on patterns of adherence and resistance were available for sub-Saharan Africa, Blower's maths models had been compared with on-the-ground studies done in San Fransisco, so her work was not merely predictive. Virologist Prof Alan Smith further observed that the data gathered in Europe for this study involved equally complex population profiles, such as sex workers and intravenous drug-users. He also noted that far greater vigilance is required to monitor ARV resistance, as HIV is so virulent in its invasiveness. Dr Pawinski's talk concluded with reference to an Index for ARV Readiness Assessment (JSI), a useful tool developed by USAID for public health practitioners and other stakeholders. [To download Pawinski's PowerPoint presentation, simply click on the link in the righthand column].
The session proceeded with Professor Alan Berkman, of the Mailman Mandela Initiative, reflecting informally on his recent experiences over a six-month period of mass-scale ARV roll-out in the Dominican Republic.
This work was funded by the Clinton Foundation, which raises financial aid with a focus on care and treatment applications, and draws on the expertise of high-level retired business figures to assist in managing the epidemic from a strategic planning perspective. "The Dominican Republic went through a similar process as did KZN province in its bid for finance from the Global Fund," Berkman explained. "They had great plans, but no actual money was released, so the Clinton Foundation stepped in with seed funding to tide them over. The HIV prevalence there is much lower than that in KZN, but numbers matter a great deal if planning is to be effective."
He said that two different methods of determining levels of HIV infection were used: "sentinel surveillance", which uses data gathered from VCT programmes at ante-natal clinics and amongst groups of MSMs and sex-workers, yielded a figure of 2,2%. A broader, community-based, country-wide sample of 30 000 rendered a figure of 1,1%. In pulling the findings together, it was acknowledged that one million Haitian sugar-cane cutters living in work-camps had not been factored into the sample, and in the final analysis the more accurate epidemiological percentage was estimated to be around 1,6%. "Only five to 10 percent of those estimated to be HIV-positive actually knew their status," said Prof Berkman. "So, one can plan things in theory, but if the stigma around the epidemic is so great that accurate figures cannot be obtained from verifiable VCT-centre data, planning will be only as good as the estimate."
As the number of VCT centres in the DR was inadequate, and trained counsellors could not be paid directly from Health Ministry funds, NGOs had to be contracted to provide capacity in this area. Celebrity figures like the Dominican Republic's Miss Universe and well-known baseball players promoted awareness messages. Listing several key points by way of advice for KZN and other provincial roll-out programmes, Prof Berkman observed that: "There is a difference between a funding proposal and an operational plan, that is, the actual steps required for implementation - for this, one needs management expertise. This is especially important given that one is taking the normal medical model of 'one-doctor-to-one-patient' and applying this in terms of a team of healthcare workers to large groups of patients." "The role of nurses in such programmes is huge, and the importance of things like good protective equipment should always be on the radar screen for budgeting," he continued. "In these settings, healthcare workers are not even equipped with gloves, and yet such seemingly minor details are crucial for routine use in this work."
"Also, because there simply are not enough senior or specialist doctors available in the programmes, one ends up with the most inexperienced doctors performing Caesarian sections on HIV-positive pregnant mothers! One cannot overestimate the kind of administrative, evaluative and monitoring capacity needed in these circumstances."
Prof Alan Smith asked whether stigma around the epidemic was as severe as was being encountered in KZN. Prof Berkman could not make an informed comparison in this regard, but confirmed that HIV/AIDS was highly stigmatised in the Dominican Republic, and that many citizens did not want to be tested. "It's considered to be the same as leprosy," he explained, "with the idea of a fatal disease that involves a slow, agonising death - so it helped enormously to have HIV-positive role-models living quite healthy lives on ARV treatment as the advocates for VCT." For the full report on the Journal Club session, please click on the righthand side of this page. |
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