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Scaling Up Treatment for the Global AIDS Pandemic: Challenges and Opportunities
to collect, WHO surveys and general reports indicate that human resource capacity is generally extremely weak in such settings and in many places is a critically limiting factor in providing access to ART. In fact, some evidence suggests that ART scale-up could fail on these grounds alone (Kober and Van Damme, 2004). Many of those countries with the highest numbers of people living with HIV/AIDS have very few health care providers trained in comprehensive care for the disease (Liese et al., 2003; USAID, 2003). Many health workers have died as a result of untreated AIDS, and others have moved to wealthier countries in search of better pay and job security (Padarath et al., 2003; Pang et al., 2002; Tawfik and Kinoti, 2001). (For an extended review of human resource capacity considerations, see Appendix C.)
In acknowledgment of this situation, WHO’s 3-by-5 plan calls for the rapid training of tens of thousands of workers to aid in the delivery of ARVs. However, the medical complexity of HIV/AIDS therapy cannot be overestimated. Nor can the logistical complexity of reliably delivering ARVs to their intended destinations—a recurring process that can demand significant organizational skill and infrastructure—be ignored. Rapid scale-up will require sufficient expertise in all of the various nonmedical components of ART programming, as well as the more obvious health-sector roles. The problem is compounded not only by the shortage of trained workers with specific HIV/AIDS experience or expertise, but also by severe shortages in many resource-constrained settings of the well-trained professionals needed to handle other critical functions, such as commodity logistics, pharmaceutical regulation, laboratory support, information management, and operations research.
The seriousness of the situation is illustrated by an October 2003 report analyzing the cost and resource requirements associated with providing ART through the Zambian public health sector (Kombe and Smith, 2003). Despite key findings indicating that the provision of highly active antiretroviral therapy (HAART) to all clinically eligible patients will be prohibitively expensive, the report suggests that human resource capacity may become the most critical rate-limiting factor.
In the report, the estimated per-patient cost of the health care training necessary for public-sector ART scale-up in Zambia, with an initial goal of providing ARVs to 10,000 people, is US$3.70, which amounts to a total overall cost of $37,000 per year. That amount, which represents less than 1 percent of the estimated total per-patient cost (i.e., $488), would cover the marginal requirement for the estimated additional 13 full-time equivalent (FTE) doctors and nurses, 15 FTE pharmacists, and 32 FTE laboratory technicians needed to provide ART to 10,000 patients. Although the demand for laboratory technicians poses a challenge, meeting the overall workforce needs for achieving Zambia’s initial scale-up goal is quite fea-