IOM report urges immediate rollout of HIV/AIDS initiatives in developing world

07/06/04

Calls for new partnerships, 'HIV/AIDS corps' to address to work-force crisis

WASHINGTON -- International aid organizations and governments should proceed immediately with the rollout of several major new programs to deliver HIV/AIDS care on a large scale in the developing world, while also determining ways to reduce the likelihood of treatment failure and drug resistance, says a new report from the Institute of Medicine of the National Academies. With substantial cuts in antiretroviral drug prices and an influx of billions of dollars in donations, the greatest obstacle now facing these large-scale initiatives is a critical shortage of qualified health care workers and support personnel in the resource-poor countries where the epidemic is most severe. This shortfall should be addressed through partnerships, technology transfer, and the mobilization of a Peace Corps-like "HIV/AIDS corps" of technical specialists, said the committee that wrote the report.

"While we should proceed with caution and care given the many challenges that lie ahead, we should not delay; we must act now to rein in the global AIDS catastrophe," said committee co-chair James Curran, dean and professor of epidemiology; and director, Center for AIDS Research, Rollins School of Public Health, Emory University, Atlanta.

"Solving the AIDS crisis will take more than just inexpensive drugs, however," added co-chair Haile Debas, director, global health sciences, and professor of surgery, University of California, San Francisco. "Success now hinges more on having adequate infrastructures to distribute therapies and sufficient numbers of trained health care workers in developing countries. Even if we had enough money right now to buy all the necessary drugs to treat every infected individual, global expansion of treatment and prevention could fail just because of the scarcity of trained personnel."

Approximately 40 million people worldwide are infected with HIV, and 6 million need antiretroviral therapy now. Only about 400,000 people in developing nations have access to treatment. With 5 million additional people infected by HIV each year, the number of people needing treatment will only increase. The committee's report offers an independent, expert assessment of existing and proposed initiatives to scale up HIV treatment in developing countries, and it provides a framework and key principles to guide the rollout and expansion of these programs.

WORK-FORCE CRISIS

Significant expansion of HIV/AIDS treatment and prevention will require tens of thousands of health care workers with the experience and training to treat millions of people who have a disease that requires a complicated and long-term regimen of care. In addition, workers with other types of technical expertise are needed to run the daily operations and manage the complex process of reliably delivering therapies to their intended destinations. The lack of an adequate work force in poor nations reflects the underlying crisis of inadequate access to high-quality education throughout the developing world, the report says. Furthermore, most of these nations are experiencing a "brain drain," as many of the limited pool of educated and trained individuals migrate to other areas or countries that offer a better quality of life. Not only are there not enough skilled workers to conduct and manage HIV/AIDS treatment expansion now, but the numbers also are shrinking, the committee found.

A variety of innovative government and private-sector programs should be developed or expanded to bring a corps of volunteer medical and other professionals from resource-rich nations into developing countries to train their citizens in HIV/AIDS treatment and prevention and provide technical assistance, the committee said. This "HIV/AIDS corps" initiative would strengthen long-term ties among health professionals and others working to fight the disease in all countries, the report says.

Donors financing the global fight against HIV/AIDS should encourage partnerships among clinics, hospitals, and other medical institutions within and across national borders. Expertise developed through the AIDS education and training networks sponsored by the U.S. government, as well as similar initiatives in other countries, should be used to shape new training programs. Technology transfer and knowledge sharing also are needed among academic institutions, industry, public health agencies, and nongovernmental organizations to strengthen the work forces in developing nations.

LEARNING BY DOING

Tackling AIDS on a global scale should be based as much as possible on established public health practices, but it also will necessarily involve much learning by doing, the committee said. Several experts have expressed concerns that problems with organization and patient adherence to the therapy regimen in large-scale HIV/AIDS initiatives could lead to faster development of drug resistance, which ultimately could result in widespread treatment failure.

The committee urged that in addition to building on successes, program managers use mistakes and setbacks as learning opportunities. Efforts to control the epidemic in developing nations are still too new to have produced much evidence of which tools and methods work best in these nations, and most existing knowledge comes from research and treatment in the United States and other resource-rich countries. While some of the knowledge gleaned from these industrialized countries is applicable to developing nations, much will need to be reassessed.

About 5 percent to 10 percent of donor funding should be earmarked upfront to go toward monitoring and evaluation, the report says. These activities are important because the data gleaned from them will be critical for improving HIV/AIDS programs, identifying best practices that can be shared with others, and assuring donors that the programs are working, the committee said. The standards and methods for monitoring and evaluation need to be harmonized across all initiatives to minimize inefficiencies and maximize the ability to make comparisons among programs.

Although they have some limitations, the World Health Organization's guidelines for the treatment and monitoring of HIV-infected individuals should serve as an initial template that program managers and governments can use to tailor programs for their countries, the report says. The WHO guidelines acknowledge some uncertainties and will require modification as experience and research findings accumulate. However, they provide a useful starting point by outlining simple criteria and steps that can be used in even the most resource-poor settings, thus standardizing and simplifying treatment.

FIXED-DOSE COMBINATIONS

Fixed-dose combinations (FDCs) -- single pills that contain multiple drugs -- should be used, but only if they are shown to be safe, effective, and of high quality, the committee said. Many experts tout the ability of FDCs to improve adherence to treatment by reducing the number of pills that people have to take each day, and they usually are less costly. However, concerns have been raised about developing nations' abilities to ensure that FDCs -- as well as single-medication pills -- are of consistent quality and effectiveness, especially as less-experienced manufacturers enter the market and compete to produce drugs. A standardized, rigorous, international quality-assurance process for drug production must be developed, the report says.

"While costs are a factor, what is most important is that any drugs used are of proven quality and efficacy," Curran said. "Having less-effective drugs in these environments could do more harm than having no drugs at all."

LONG-TERM FUNDING COMMITMENT

Ensuring the best chances of success will require commitments from donors to provide continuous funding for decades, the report noted. Although WHO has set the ambitious goal of placing 3 million individuals on antiretroviral treatment by the end of 2005, tens of millions more infected people will reach the point at which they need therapy over the next decade. UNAIDS estimates the total annual need for HIV/AIDS funding to be $10.7 billion for 2005 and $14.9 billion by 2007. The total estimated funding provided in 2003 was $4.2 billion.

ADDITIONAL TREATMENT NEEDS

Programs to control tuberculosis should continue to operate in parallel with initiatives to scale up HIV/AIDS treatment, the report urged. Nearly one-third of HIV-infected individuals also have tuberculosis, which is one of the leading causes of AIDS-related death. Tuberculosis treatment programs already established in many developing countries should be supported as an important point for entry into HIV testing and treatment.

In addition, HIV/AIDS program planners should develop and enact stronger, more effective efforts to prevent HIV infection at the same time that they expand treatment, the report says. Prevention efforts should focus on those at risk for becoming infected, not just those receiving treatment.

The study was sponsored by the Fogarty International Center and the Office of AIDS Research at the National Institutes of Health; and the Bill & Melinda Gates Foundation. The Institute of Medicine is a private, nonprofit institution that provides health policy advice under a congressional charter granted to the National Academy of Sciences. A committee roster follows.

A pre-publication version of SCALING UP TREATMENT FOR THE GLOBAL AIDS PANDEMIC: CHALLENGES AND OPPORTUNITIES is available on the Internet at HTTP://WWW.NAP.EDU. Reporters may obtain a copy from the Office of News and Public Information (contacts listed above).

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