December 2002 HIV/AIDS Public Health Journal Club

The last Journal Club meeting of the year featured Andy Gray and Dr Donnie Mcgrath from the Department of Experimental and Clinical Pharmacology at the University of KwaZulu-Natal's Nelson R Mandela School of Medicine in Durban. Their presentations focused on recent clinical and logistical reviews of "Making ARVs available in resource-poor settings".

Gray's point of departure on this issue was based on how stakeholders might move from "good intentions" to practical implementation. He displayed a useful list of essential components for ARV access as outlined by WHO/EDM, these being rational selection, affordable prices, sustainable financing and reliable health and supply systems.

He also reviewed two recent papers on the subject, viz.:

• Rabkin M, El-Sadr W, Katzenstein DA, Mukherjee J, Masur H, Mugyenyi P, Munderi P, Darbyshire J. Antiretroviral treatment in resource-poor settings: clinical research priorities. Lancet 2002; 360: 1503-1505.


• Kitahata MM, Tegger MK, Wagner EH, Holmes KH. Comprehensive health care for people infected with HIV in developing countries. BMJ 2002; 325: 954-957.


With reference to the Rabkin paper, it was noted that HAART has only been studied for six years, and that in South Africa, circumstances prevailing in certain settings would preclude standard operational systems being set up. Also, the paper does not raise issues of financing and resources. The Kitahata paper, consisting of a literature review and "...[the]personal experience, research and capacity-building activities of the faculty..." was regarded as being somewhat thin in terms of investigation, was "algorithm-guided" and did not address the problems of rational selection and affordable pricing.

Gray commented that the recommendation to use the ideal primary health care procedures set up for the delivery of chronic care was not appropriate to the highly infectious disease framework that was needed to deal with the scale of the epidemic in KwaZulu-Natal. For this reason, local practitioners were aligning ARV therapy programmes with DOTS programmes in use for the treatment of TB. He concluded by saying that neither paper tells us anything we do not already know, and that much more operational work would have to be done in situin order to arrive at meaningful solutions. The approach taken by the research under review was based on the assumption that local stakeholders have the time to build slowly from the ground up in order to perfect basic services - which is not the case.

Dr McGrath used the same articles to present on an "HIV Therapy Research Agenda", with a specific focus on how to monitor ARV programmes in resource-poor settings and using a line of enquiry based on the outcomes of "tight" versus"permissive" control of therapy. Noting that monitoring actually begins when the patient is first seen, Dr McGrath said that there were serious implications for the implementation of "tight" or strict monitoring because of the number of visits to or by the patient and of the tests required to be run. With the very complex medical management involved in HAART, and its toxicity, he questioned whether this degree of thoroughness could realistically be offered in large numbers.

McGrath also noted that if such regimens could not be made to work in resource-poor settings, the burden of care would shift from the commuinty doctors to the specialists, which would also not be viable. Furthermore, lack of adherence would result in an even wider scale of drug resistance.

Ensuing discussion revolved around the issue of how to convince government and policymakers to address these problems of ARV roll-out. Reference was made to the CIPRA-grant projects being undertaken by Wits and Natal Universities, the protocols for which take account of the issues of cost and of constantly changing data which might rapidly become redundant. These research programmes consist of 26 projects in all, involving over 200 patients.

The role of civil society in terms of practical contributions to these efforts was seen as crucial. Both presenters felt that this role should primarily address the reduction of stigma and counteracting misinformation around HIV/AIDS, specifically targeting community and traditional leaders and challenging them to visibly participate in "testing days", as had been achieved at the Hlabisa site in northern KZN.

The problem of nurses being overloaded with the work of DOTS monitoring, strict control of ARV therapy, assessment of patients and collection of data was also raised. Health officials in Botswana had already determined that they would need 5000 doctors to cope with this type of work in their country, and they do not have such capacity. Similarly, in South Africa, more community-driven creative solutions would be needed to solve this problem.

To download the PowerPoint presentation documents referred to, simply click on the links in the righthand column