WHO - Public Health www.thelancet.com Vol 368 August 5,...

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Unformatted text preview: Public Health www.thelancet.com Vol 368 August 5, 2006 505 Background Around 40 million people worldwide are thought to be infected with HIV. Many of these people live in developing countries. Since 2001, the WHO has been promoting a public-health approach to antiretroviral therapy (ART) to improve access in resource-poor settings. Existing guidelines for ART, 1,2 and the prevention of mother-to- child transmission 3 were revised earlier this year, and separate guidelines for treating children were developed. 4–6 Other publications support the public-health approach to ART delivery 7–9 and free 10 and equitable access 11 to ART. The integrated management of adult, adolescent, and childhood illness (IMAI/IMCI) has been developed to support decentralised implementation in resource-poor countries. 12 Treatment options have been consolidated into two sequential ART regimens. 2 International consensus on a simple fi rst-line antiretroviral combination for adults meant that production and supply of ARTs could be scaled-up. Once fi xed-dose combinations became widely available, and prices had fallen substantially, the WHO announced its 3 by 5 initiative (to strive for 3 million people in low-income and middle-income countries to be on antiretrovirals by 2005). 13 Although the initiative did not meet its target, by the end of 2005, around 1·3 million people were receiving WHO-recommended fi rst-line regimens, 14 compared with 400 000 in 2003. A recent assessment noted that almost all focus countries for ART scale-up had either adapted or used WHO recommendations to shape national policy; 15 treatment programmes and centres report good initial responses. 16,17 Despite these achievements, there remains considerable uncertainty about what should constitute a public-health approach to ART. We summarise here the WHO’s approach, and clarify its importance for treatment providers, HIV programme managers, and policymakers in developing countries. Why a public-health approach? Extensive evidence shows that combined antiretrovirals can substantially extend the life of those with HIV/AIDS. Guidelines for industrialised countries cover individual patient management delivered by spet doctors prescribing from the full range of antiretrovirals, supported by routine high-technology laboratory monitoring. 18,19 Such an approach is not feasible in resource-limited settings where doctors are scarce (eg, one per 12 500 population in Uganda 20 ), laboratory infrastructure is inadequate (eg, one working microscope per 100 000 population in central Malawi 21 ), and the procurement and supply-chain management is fragile. This di culty in translating guidelines from developed to developing nations caused concerns over whether ART scale-up in poor countries was feasible, let alone a ordable or cost-e ective....
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WHO - Public Health www.thelancet.com Vol 368 August 5,...

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