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Scaling Up Treatment for the Global AIDS Pandemic: Challenges and Opportunities
that micro- and macronutrients affect the progression of HIV and the bioavailability and efficacy of particular drugs. Therefore, food and nutrition assistance programs should be a resource available to those using ART. Additional nutrition-related research questions include the following:
What are the benefits of nutritional supplementation?
What are the pharmacokinetics of ARVs in populations with poor nutrition?
Implementing ART in resource-poor settings poses difficult, complex medical, technical, and logistical questions, many of which have yet to be addressed through operations research programs. Yet many would argue that the social and behavioral dimensions of scaling up ART programs raise equally, if not more, challenging questions. HIV is as much a psychosocial as a biomedical phenomenon. A behavioral science research agenda is critical to elucidating underlying factors and achieving a better understanding with regard to improving adherence to ARVs, reducing risk behaviors associated with transmission of HIV, improving the accessibility of ARVs and treatment and prevention programs, and reducing the stigma associated with being at risk and living with HIV/AIDS.
Given the high degree of susceptibility to resistance of some of the less expensive, WHO-recommended NNRTI-based ARV regimens in resourceconstrained settings, adherence will be a critically important factor in preventing or reducing treatment failure and the consequences of such failure for both patients and the population at large (see Chapter 3). Thus one of the most urgent behavioral research needs is to identify and better understand the underlying factors that contribute to poor adherence, as well as ways to improve adherence. While adherence has been determined in a variety of ways among persons living with HIV/AIDS in wealthy countries, it remains to be determined which measurement approaches are culturally best suited to resource-poor countries and whether innovative alternatives have the potential to serve as more accurate and acceptable measures.
According to a recent assessment of available evidence for HIV/AIDS interventions performed by the Cochrane Collaborative Review Group on HIV Infection and AIDS (2004), controlled trials are urgently needed to determine which interventions can improve adherence to highly active antiretroviral therapy (HAART) and whether those interventions also suppress viral load and improve clinical outcome. More research is also needed